An excerpt from Prevention First: Policymaking for a Healthier America.
Little did I know that when Prevention First was first published in December 2019, a novel virus with pandemic potential had begun to stealthily spread in China. The subsequent global COVID-19 pandemic resulted in nearly 7 million deaths, exacerbated long-standing health challenges, and led to life expectancy declines around the globe.
With over 1.1 million American lives lost during the COVID-19 pandemic, two overarching takeaways from this difficult period should be remembered by history: most deaths were preventable, and had we done nothing, millions more would have died. The first is a reminder that so many more lives could have been saved had public health interventions been embraced by the public. And the second is a reminder that the determination, innovation, and humanity of the American public limited the devastation of this pandemic.
Given this book’s main theme that prevention must be our nation’s top health policy, it is worth reflecting on whether this theme is even more important today than five years ago. Five lessons from the pandemic suggest that the answer is certainly yes.
First, leadership matters. Second, crisis communication to the public is as important as any response element. Third, access to data is crucial to having situational awareness and guiding a response. Fourth, the investments in the tools (e.g., vaccines, stockpiles, surveillance, supply chains) and people (e.g., public health workforce) required for a successful response pale in comparison to the costs of being unprepared for a pandemic. Fifth, optimally mitigating the economic consequences of a public health response requires timely and targeted aid to underserved communities.
More broadly, there are a number of overarching policy recommendations in this book, but I have chosen to underscore five that have the greatest potential to optimize health in this nation. Collectively, they call for policymakers to engage in proactive policymaking, leverage public payers, invest in public health, and encourage prevention research. Some may say that bipartisanship in politics is nice to have but not necessary. I believe that if we are to create a culture of prevention, policymakers from both sides of the aisle will need to equally provide leadership and support.
1. Each administration and leadership team at the Department of Health and Human Services (HHS) should make disease prevention its top priority. A limited set of specific metrics should be associated with the department’s prevention goals, and these should be aligned with Healthy People. Tackling the upstream determinants of health, community prevention, clinical prevention, primary care, public health, and global health should be the focus of each presidential administration.
2. Health care providers should be incentivized through quality measures not only to manage chronic diseases but also to prevent them. As health care moves slowly from a volume- to value-based payment system, quality measures are the currency through which payment will be provided. Moving forward, health status measures related to the incidence of chronic diseases and the prevalence of chronic disease risk factors should be developed, endorsed, and used by the Centers for Medicare and Medicaid Services and private payers. Increasing accountability of health care entities for health status measures will catalyze the clinical-community linkages necessary to keep vulnerable Americans healthy and reduce preventable health care costs.
3. A regulatory pathway needs to be developed to allow for community-based prevention programs to be deemed safe, evidence-based, and worthy of coverage and payment by Medicare and subsequently private insurers. In the present system, drugs, devices, and other medical interventions undergo an established process to gain approval by the FDA for their safety and efficacy; in most cases, this triggers coverage determinations by Medicare based on the standard of the intervention being reasonable and necessary. A similar pathway does not exist for community-based interventions, even though millions of Americans stand to benefit from evidence-based programs in areas such as falls prevention, physical activity promotion, and chronic disease self-management.
4. Congress should provide robust funding for public health efforts to support population health and well-being. Specific priorities include increasing funding to enhance domestic public health capabilities, boosting the existing public health emergency fund, and supporting impactful global health projects. Public health functions need to be viewed as part of our nation’s infrastructure in the same way as sectors such as transportation, energy, and information technology. While it’s true that too many Americans take the functions of public health for granted, public health must also become more participatory for the average citizen. The field must do a better job not only in explaining its role and how it relates to the daily activities of Americans but also in finding specific ways for Americans to support local public health efforts.
5. Federal support for prevention research is not prioritized and needs to be enhanced to match its potential impact. Along with basic science research to identify opportunities for disease prevention, there needs to be more clinical, health services, and public health research in this area. Increased federal funding availability for prevention research from Congress will attract additional researchers to the field. This will result in more published studies and a better evidence base to deploy and scale effective interventions. More robust information on the cost-effectiveness of prevention interventions will also assist the Congressional Budget Office in being able to score future federal legislation related to prevention.
These actions taken by policymakers could help transform the nation’s health policy conversation. Our dereliction in glossing over prevention—either because we assume that prevention is too difficult or we fear that it is too intrusive in its pursuit of adapting human behavior—has real consequences. And these consequences come in the form of millions of Americans dying from preventable causes of deaths each year and millions of others suffering from preventable chronic diseases. We can do better. In fact, we must do better.
Anand Parekh is an internal medicine physician and author of Prevention First: Policymaking for a Healthier America.
