HealthLawProf Blog

Editor: Katharine Van Tassel
Concordia University School of Law

Thursday, February 5, 2009

Public Health and the Stimulus

Harold Pollack public health policy researcher and faculty member at the University of Chicago's School of Social Service Administration, writes in the New Republic's Treatment Blog about his displeasure over the removal of certain public health measures from the stimulus bills in Congress, and explains why these provisions were seemingly so easy to remove.  He states,

What is remarkable and galling is the way Senate critics focus like a laser beam on the smallest, most defensible, glatt kosher items.

This in today’s Washington Post:   The most ambitious effort to cut the bill is being led by Sens. Ben Nelson (D-Neb.) and Susan Collins (R-Maine), moderates in their parties who share a dislike of the current version. Collins is scheduled to visit Obama at the White House this afternoon. "I'm going to go to him with a list" of suggested deletions, she said….Among the items that the Collins-Nelson initiative is targeting: $1.1 billion for comparative medical research, $350 million for Agriculture Department computers, $75 million to discourage smoking, $20 million in Interior Department funding, $400 million for HIV screening and $650 million for wildlife management.

I don’t know about the Agricultural and Interior Departments or managing wildlife. I do know about the health stuff. These provisions don’t belong on anyone’s list to cut.

Comparative medical research is a high priority by any conceivable measure. Candidate Obama and Candidate McCain both advocated major investments here to improve the quality and cost-effectiveness of care, and they were right. An astonishing proportion of American medical care has never been rigorously evaluated, or outright fails to meet reasonable thresholds of quality and cost-effectiveness.   As Ezekiel Emanuel put it in his book Healthcare, Guaranteed: “The United States spends over $2 trillion on healthcare, about $200 billion on prescription drugs, and nearly $100 billion on medical research and development, but only a paltry $1 billion to evaluate the comparative costs and effectiveness of medical interventions and their influence on health outcomes.” . . . .

Washington conventional wisdom has fastened on HIV/STI/TB prevention and related services as tangential and unworthy stimulus items. (I won’t even discuss family planning, which was dropped with predicable but depressing alacrity.) In policy terms, these efforts are unobjectionable. Inflation-adjusted federal expenditures on HIV prevention have markedly declined since 2002, despite rising numbers of new infections. Our society faces other serious challenge from other sexually-transmitted infections, and from tuberculosis, too. A large body of evidence-based interventions could attack these problems with monies appropriated in the House stimulus bill.

Perversely, the obvious social value of public health investments has become a mark against them in the current stimulus debate. Critics worry that someone might support these policies because they are sensible and humane, not merely because they shovel some quick money into the economy. I guess the charge rings true. Yet as a mechanism of economic stimulus, hiring nurses and counselors to prevent unintended pregnancies or HIV infection is no less worthy than hiring burly construction workers to build a road. Public health measures are a lot cheaper. They are a hell of a lot less likely to stiff taxpayers for an environmentally dicey boondoggle. . . .

As my colleague Jens Ludwig points out, public health measures are vulnerable because they are not porky enough. They do not slide neatly into the grooves of American interest-group politics. Public health policies have an unfortunate tendency to improve health among diffuse, disorganized, or politically marginal constituencies. These policies provide too little gravy to organized and powerful constituencies. Although many interest groups and many politicians claim to support public health and prevention, few care quite enough to support these values once the shoving starts.

It’s time to shove back.

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