摘要：The nation once again is on the precipice of financial catastrophe, but have we overlooked public health? Juxtaposed against one another, the comparison of health care with public health—one largely overutilized, expensive, and underperforming, the other responsible for eradicating diseases and providing safe food and water—cries out for thoughtful fiscal recalibration. We have examined the recent Institute of Medicine report on public health financing and made actionable recommendations for sustainable public health financing. THE NATION HAS ONCE AGAIN avoided going over the precipice of yet another cataclysmic financial catastrophe, affectionately termed the “fiscal cliff.” This manmade disaster resembles others in our recent history including the so-called debt ceiling compromise that set the stage for the current crisis and is scheduled to be revisited in early 2013. Although these 2 events share the potential to produce a US fiscal nightmare and a date certain for events to begin unfolding, there is another fiscal cliff our country has waltzed over in virtual slow motion with equally dire consequences. Over recent decades we have spent lavishly on health care, outstripping expenditures of other developed nations by more than twofold, even as other societal needs have been overlooked. 1 Yet the return on our present $2.7 trillion investment in health has been extremely modest. 2 Moreover, even a nation as wealthy as ours incurs opportunity costs. The vast resources committed to health care are unavailable to be invested elsewhere: in education, social programs, and vibrant communities—the very investments in social and environmental determinants of health that pay returns in the form of health dividends. Worse, not only do we lead the planet in health expenditures, but we also lag behind most developed nations in health outcomes for communities as well as individuals. 2 In short, from a value proposition perspective, we spend too much and gain too little. Even as health care expenditures skyrocket, accounting for an ever growing share of the projected sea of red ink that is the federal budget forecast, public health expenditures stagnate or decline. 3,4 In fact, spending on governmental public health is a rounding error considering the size of the overall health budget, a mere fraction estimated at less than 2.5% of total costs. 5 Ironically, public health has been triumphant, accounting for the major proportion of US life expectancy gains achieved in the 20th century. 6 Juxtaposed against one another, the comparison of medical care with public health—one overutilized, expensive, and underperforming, the other responsible for eradicating infectious diseases, decreasing by half the incidence of cardiovascular disease, and providing safe food and water among other societal advances—cries out resoundingly for a thoughtful fiscal recalibration.
