Election night 2008 was a promising moment for public health. The Bush era had brought political acrimony, managerial problems, and under-funding had brought severe morale problems to the alphabet soup of federal agencies concerned with population health and safety-net care. It was therefore a powerful relief to greet new leadership under a presidential administration and House majority notably sympathetic to public health.
The past 50 months have brought worthy accomplishments in tobacco control, child obesity, substance abuse, and in much else. It’s still been tougher sledding than many of us had hoped. As general concepts, population health and prevention attract universal rhetorical support. Yet as practical measures in a political fight for scarce resources in hard times, public health has proved distinctively vulnerable in Congress and across the states.
The Centers for Disease Control and Prevention and other federal public health agencies have faced flat or declining funding. With almost surgical precision, the lowest-income states with the worst population health outcomes resist the Affordable Care Act (ACA)’s most important public health provision: its Medicaid expansion. Meanwhile, ACA’s Prevention and Public Health Fund, originally slated at $15 billion, remains the target of repeated cuts, congressional criticism, and conspicuously tepid White House support.
HIV/AIDS provides a hallmark example of the opportunities we are allowing to slip away. It’s by no means the most neglected public health problem. It’s merely one area in which the human consequences of such neglect are particularly acute.
Almost 640,000 Americans have died after being diagnosed with AIDS. Remarkable treatment advances have reduced the death toll. Yet 20,000 Americans living with HIV still die every year, an annual death toll that exceeds the rate of U.S. combat deaths in Vietnam.
The HIV prevention effort is also falling short. The annual number of new HIV infections has remained basically unchanged since the early 1990s, with roughly 50,000 Americans newly infected every year. The number of new HIV infections among men who have sex with men is slightly higher today than it was twenty years ago. At this rate, striking proportions of sexually-active gay and bisexual men will be infected.
The Obama administration offers a good national strategy. Yet the money isn’t there to really execute what must be done. Stuck in artificial crises such as the current sequester mess, our policy process seems unable to focus on real public health problems. Meanwhile, we let opportunities to help slip away.
More here from me with some wonky graphs, at the Washington Post’s Wonkblog section.