Evolution of Public Health

The steps we’ve taken to build a more sustainable and resilient system Jim Mange February 2018 Web Exclusive

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When thinking about public health, many of us, me included, think about well-known interventions such as sanitation, immunization and disease detection. The Centers for Disease Control and Prevention (CDC) identifies the 10 great public health achievements¹ of the 20^th century as:

• Vaccination
• Motor-vehicle safety
• Safer workplaces
• Control of infectious diseases
• Decline in deaths from coronary heart disease and stroke
• Safer and healthier foods
• Healthier mothers and babies
• Family planning
• Fluoridation of drinking water
• Recognition of tobacco use as a health hazard

Public Health 1.0

This is Public Health 1.0, and despite popular perception,² these achievements explain more³ of the dramatic improvement in health and life expectancy in the United States during the 20^th century than the simultaneous remarkable advancements in medical care and technology.

In this web exclusive series of The Actuary, Geoffrey Sandler, FSA, MAAA; Kari D. Berglund, MSc; and Sara C. Teppema, FSA, MAAA, explore two of these achievements: vaccination and family planning. Geoffrey discusses the challenges we face encouraging reluctant members of society to be vaccinated. Kari and Sara outline the history of long-acting reversible contraception methods and offer a simple actuarial model that could be used to derive estimates of the cost savings that might be realized if greater use was made of these methods. They suggest potential opportunities for extending the model so that long-term benefits to society might be incorporated.

By the late 20^th century, these interventions had largely been integrated into the fabric of society. For example, with limited exceptions, vaccinations are required to enter public school. Federal and state laws establish minimum standards for motor vehicle, food and workplace safety, as well as clean water and air. The outrage⁴ with which the Flint water crisis was greeted only highlights how successfully we normally manage our water supply, but how devastating the effects are when we do not.

During the 1980s, public health professionals recognized that, despite these extraordinary successes, vulnerable populations remained and new threats to public health—for example, HIV/AIDS and chronic diseases—were emerging. To address these concerns, public health professionals began to re-conceptualize public health as not merely a series of targeted interventions that could be scaled up to protect or improve conditions for many, but as a complex, integrated system involving “all public, private and voluntary entities that contribute to the delivery of essential public health services within a jurisdiction.”⁵ As an integrated system, they concluded, the public health system delivers 10 essential services:⁶

1. Monitor health status to identify and solve community health problems.
2. Diagnose and investigate health problems and health hazards in the community.
3. Inform, educate and empower people about health issues.
4. Mobilize community partnerships and take action to identify and solve health problems.
5. Develop policies and plans that support individual and community health efforts.
6. Enforce laws and regulations that protect health and ensure safety.
7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable.
8. Assure a competent public and personal health care workforce.
9. Evaluate effectiveness, accessibility and quality of personal and population-based health services.
10. Conduct research for new insights and innovative solutions to health problems.

Public Health 2.0

This is Public Health 2.0. Two other authors in this web-exclusive series, Shereen Sayre, ASA, MAAA, and Jason McKinley, FSA, discuss how the insurance industry might contribute to a more fully integrated system. Shereen suggests that, due to the historical accident that medical and dental insurance are separate products, health professionals often fail to treat the “whole person.” This failure sometimes leads to vicious cycles in which chronic medical conditions lead to dental infections that, in turn, exacerbate other chronic medical conditions. In a potentially innovative solution, Jason suggests that insurers offering fully underwritten medical policies should not just price for suicide exposure, but manage it. With the information at their disposal, insurers could identify and undertake interventions in respect to individuals who may have the potential to commit suicide.

A third author, Rebecca Owen, FSA, MAAA, describes the opioid crisis and its grisly consequences. As with many public health crises, it will require an “all hands on deck” approach, including actuaries, to address both its near- and longer-term consequences.

Lisa Macon Harrison, MPH, and Marjorie Rosenberg, FSA, Ph.D., consider the public health system as a whole. Marjorie describes an initiative by the Robert Wood Johnson Foundation to promote a broader “culture of health” in the United States. She acknowledges the divergent views about the role of government in promoting health both within society-at-large and, more specifically, among actuaries. She suggests possible approaches to developing workable solutions despite these differences. Lisa describes the fragmented way in which public health is financed in the United States, rendering a vulnerable system evermore fragile. She asks actuaries to bring their deep knowledge of health care financing and analytical skills to bear in building a more sustainable and resilient system.

Public health professionals today recognize that Public Health 2.0—with its focus on assessment, assurance and policy development—is not meeting the challenges we expect to face as the 21st century approaches its third decade. A next generation framework—one that recognizes the determinants of health— is needed. In his 2007 article, “We Can Do Better—Improving the Health of the American People,”⁷ Steven A. Schroeder, M.D. shows that only 10 percent of early deaths in the United States are explained by inadequate medical care. Our genes and behavior and our social and environmental living conditions explain the remaining 90 percent. The last two are the “social determinants”⁸ of health, and addressing these is the next great challenge in public health.

Public Health 3.0

This is Public Health 3.0. Four authors of this web-exclusive series discuss elements of Public Health 3.0. When you hear the phrase “climate change,” you probably think about effects on our physical environment. Mona Sarfaty, M.D., MPH, FAAFP, points out that such change has downstream consequences that affect all our health. In a sidebar, Jeff Beckley, FSA, MAAA, chair of the Society of Actuaries’ (SOA’s) Climate and Environmental Sustainability Research Committee, offers thoughts on how actuaries can contribute to managing these risks. Finally, Sudha Shenoy, FSA, MAAA, CERA; and Michelle Mickey Rork, MPA, MPP, describe the evolution of Oregon’s Medicaid system from fee-for-service through managed care to its current form, community care organizations (CCOs). They explain how actuaries helped in the development of CCOs and suggest other potential areas for actuarial analysis and improvement.

The fact that public health professionals today are building Public Health 3.0 doesn’t mean that issues addressed by Public Health 1.0 and 2.0 are resolved. They are not. For example, outbreaks of infectious disease illustrate the need to continue delivering Public Health 1.0 solutions. Another example: “Linking people to needed personal health services …” a Public Health 2.0 service, remains a challenge⁹ today despite the reduction in the uninsured population over the last several years.

The emergence of Public Health 3.0 focuses attention where it belongs: on health, not health care or health care delivery. It won’t be easy, but the potential dividends, both for individuals and for society, are enormous. Won’t you join us?