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Ellen Andrews Public health has a free-rider problem

January 4, 2019

Public health is the best deal on the planet. It’s how residents of other countries live longer, healthier lives than Americans at half the cost. But Connecticut expects our under-funded public health system to solve this intractable health problem while all the savings go to the inefficient health care system that created the problem.

Free rider is an unflattering economic term. Anyone who gets a benefit without paying their fair share is a free rider. For example, in student group projects there is always one free rider who doesn’t do any work but who still benefits from everyone else’s effort and gets the group grade. Connecticut spends only $29 per person, less than most states, on public health but $9,859 on health care services, more than most states. The health care system, that treats sickness, is a free rider on the efforts of public health professionals who keep us all well.

Public health is under appreciated. We all know health care providers and the critical services they provide to make us better. But we don’t necessarily recognize all the hardworking public health professionals who keep entire populations healthy. We should thank public health when we eat in clean restaurants, drink clean water, are treated in safe health care facilities, and don’t get an infection from a haircut or pedicure. Public health’s responsibilities include tracking and preventing deadly epidemics, promoting healthy behaviors like quitting smoking, exercise, and healthy eating, vaccination programs, and protection from environmental health hazards.

There is a growing recognition that the impact of health care services on outcomes is limited. Studies estimate that health care services account for only 10 percent of premature deaths, while public health factors account for 60 percent. Public health has led efforts to address the social determinants of health, tackling problems such as inadequate housing, unhealthy food, building safe and supportive neighborhoods, poverty and inadequate education. It has taken awhile, but the health care system is coming to recognize the importance of social determinants in health.

There is still a great deal of work to do, as health care leaders tend to think of population health in terms of their insured members or their patients, while public health officials are concerned with all of us, especially those without links to health insurance or providers. Health care systems are beginning to understand that writing a prescription for a patient who can’t afford to fill it won’t help, discharging a homeless patient back to the streets won’t work, and if patients can’t afford healthy food, it will be harder to heal.

Unfortunately, recognition of social determinants by health care systems so far has been limited to new payment models pushing financial incentives to make referrals to already strained public health and community resources. But when costs go down, payers, health care systems and providers split up all the savings. There is no compensation for the increased responsibility laid upon public health and community resources, which just adds to the imbalance.

At a recent meeting of local health directors, we learned about exciting new tools to connect public health and health care systems. When I asked about the free rider problem, there were a lot of nodding heads in the audience. The answer was that public health should do it anyway because it’s the right thing to do. Unfortunately that’s not sustainable. Connecticut’s public health professionals are already doing more with less. Expecting them to also solve our over-funded health care system’s cost problems, without new resources, is not realistic. Public health is a public good. To lower health costs and keep people well, we have to invest in public health.

Ellen Andrews, PhD, is the executive director of the CT Health Policy Project. Follow her on Twitter @CTHealthNotes. This column first appeared on CTNewsJunkie.com.

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