From the New England Journal of Medicine,an article on the strains between medicine and public health and a possible way to address them.
Faced with the growing pressure to reduce the federal budget deficit, government leaders have increasingly turned their attention to reducing health expenditures. In this atmosphere of austerity, public health programs are likely to be hit particularly hard as they compete for funds against the health care delivery juggernaut and as state and local governments, which carry out the bulk of public health activities, are forced to make further cuts.
The political vulnerability of public health financing was clearly illustrated in 2011 by Congress’s attempt to repeal the Prevention and Public Health Fund created by the Affordable Care Act (ACA), with House Republicans labeling it a $15 billion “slush fund.” The Obama administration, though it initially threatened to veto a repeal bill, ultimately mounted a more tepid defense, proposing to cut $3.5 billion from the fund as part of the President’s deficit-reduction plan. Many public health leaders believe this move is shortsighted and will hamper efforts to improve population health and reduce medical spending.
Taking a longer view, disease-prevention advocates assert that skyrocketing health care costs must not crowd out investments in public health; they point to what should be common goals in both fields and an arguably disproportionate allocation of resources to the health care delivery system. Indeed, whereas inadequate medical care accounts for 10% of premature deaths in the United States, behavioral patterns, social circumstances, and environmental exposures have a far greater effect, accounting for roughly 60% of deaths.1 Yet despite these compelling data, public health programs receive less than 5% of U.S. health spending, an amount that does not even reflect the latest budgetary squeeze.2
This seemingly imbalanced approach to health investment reflects a long-standing schism between medicine and public health, which remain professionally and institutionally distinct despite past calls for a closer bond.3 Ideally, population health would benefit from the integrated, complementary activities of a cooperative health sector. Often, however, the predominant interaction between a clinic or hospital and the local public health department is mandatory reporting of communicable diseases. Meanwhile, physicians and health care systems seeking to promote population health generally do so at their own expense, which leads to missed opportunities for both collaboration across health disciplines and potential cost savings.
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