Current U.S. Public Health Policies Undercut Economy, National Security, Says ASTHO Leader

The federal government's failure to adequately fund public health programs continues to fuel a public health crisis that has weakened the nation's economy and security while also making Americans far less healthy than their counterparts in other industrialized nations. That's according to family physician Paul Jarris, M.D., M.B.A., executive director of the Association of State and Territorial Health Officials, who delivered the keynote address at the AAFP's 2009 State Legislative Conference here on Nov. 21.

Federal officials have failed to link health care with public health efforts and, thus, have relegated public health to a secondary status that has had devastating consequences for the country, said Jarris. He noted that the United States spends 16 percent of its gross domestic product on health care, which is double what any other industrialized nation spends, but the United States is the least healthy of any industrialized nation.

Forty-three countries have a higher average life expectancy than the United States, and 40 countries have lower infant mortality rates than the United States, "leaving this country somewhere between Cuba and Albania in terms of the health of its population," Jarris said. "I don't think anyone seriously believes we have the best health care system in the world. We are doing lousy in terms of health."

Jarris characterized the current health care system as "unreliable" and plagued by a lack of quality. Only 40 percent of individuals with hypertension in this country are controlled to treatment standards, and only 20 percent to 25 percent of patients with diabetes are adequately controlled based on five diabetes management parameters, said Jarris.

In addition, noted Jarris, although studies have repeatedly demonstrated that primary care improves overall health care and lowers costs, only 5 percent to 6 percent of every U.S. health care dollar goes to primary care.

"You get what you pay for, and we don't value primary care," Jarris said. "We don't value prevention, and we don't value public health in this country. That is exactly the reason we spend so much money, and people are unhealthy."

Jarris said public health and family medicine should work together because both professions share the same perspective. He also urged family physicians to make national security and economic arguments when calling for more primary care and prevention.

"Are we talking about national security and how family doctors can contribute to national security through good primary care prevention?" he asked audience members. "Because we should be."

At the same time, family physicians have to emphasize the economic benefits of prevention and primary care, laying out the case to employers and explaining how prevention and primary care affects the nation's ability to compete with other countries in the global market place.

Jarris quoted renowned linguist Noam Chomsky, who said the strongest tool of propaganda is framing the issue. By framing the issue, you define what is in the solution set, said Jarris. "In this country, we have framed the issue as health care, not health. If we were trying to create a healthy population, we would be talking about a whole lot more than just how much it costs to give people access to health insurance."

In the United States, 97 percent of health care dollars go to health care, even though 90 percent of what affects a patient's health takes place outside the realm of health care, said Jarris. Behaviors are the largest determinants of health in this country, followed by genetic predispositions, social circumstances, health care and the environment. Yet only 42 states have heart disease and stroke prevention programs, although heart disease and stroke are the No. 1 and No. 3 killers in this country, respectively, Jarris said. Only 23 states have obesity grants from the CDC, and the last time the CDC issued these grants, 13 states lost their grants, Jarris said.

"They obviously cured obesity," he joked, prompting laughter from the audience. "They didn't need those grants."

One of the biggest misperceptions of the entire health care reform debate is that insurance coverage guarantees access to care, a supposition that Jarris noted "is simply wrong."

In 2006, Massachusetts enacted a law requiring its residents to carry health insurance, and the CDC responded by cutting the state's breast and cervical cancer screening funds based on the assumption that the state's residents were now insured and Massachusetts no longer needed as much grant money. The CDC's action ignored the fact that the state still needs funding for case management and wrap-around services for breast and cervical cancer screening. The end result of the cuts has been that many women in the state are not receiving these screenings, said Jarris.

Jarris also identified health inequalities as one of the biggest reasons why the United States lags behind other countries on meeting key health indicators.

A person's race, socioeconomic status and other related factors often determine the type of care that person receives, Jarris said. But most of what drives health inequities in this country occurs outside the domain of health care. Inequities include factors such as education, economics, employment status, institutional racism and bigotry, according to Jarris.

For example, in the inner cities and some rural areas, it is difficult, if not impossible, to buy healthy foods, such as fresh fruits and vegetables, said Jarris. In fact, he said, in some inner city areas, the only food available nearby is fast food, a situation that results from zoning laws requiring grocery stores to have parking available in areas where space is at a premium. Such situations "have got to change," said Jarris.