Providers this year invested in housing, anti-poverty and food insecurity efforts with the goal of long-term cost savings by creating conditions for patients to better manage their health.
But as interest in addressing social determinants has grown, action on broader public health issues has not kept up with the pace.
“Healthcare moved from downstream interventions to what I would call mid-stream interventions, but we have still failed to go upstream,” said Brian Castrucci, CEO of the de Beaumont Foundation, an organization that supports local and state public health programs to advance public health.
Meanwhile, federal funding for social services that were created to lift people out of poverty have been slashed.
In February, the White House for the second year proposed to cut funding to safety-net programs. President Donald Trump’s fiscal 2019 budget sought to trim the Supplemental Nutrition Assistance Program by 27% and Section 8 housing assistance by 20% over the next 10 years.
Republican lawmakers also lobbied to include work requirements for SNAP recipients as part of a massive bill reauthorizing payments to farmers. Ultimately, that provision—which the Congressional Budget Office estimated would eliminate up to 1.2 million people from the program—did not make its way into the farm bill that passed Congress late in the year.
The opioid crisis
The law came as the industry was making important strides in curbing opioid overprescribing, as more providers set best practices and restrictions.
“2018 was an important year. We started to push back on the epidemic,” said Dr. Bruce Siegel, CEO of America’s Essential Hospitals, the leading organization representing safety-net providers. “Hospitals and doctors are now embracing the idea that opioids have been overused.”
Yet experts say it’s large-scale federal funding of expanded treatment and prevention that would really make the difference. Most of the funding proposals included in the SUPPORT Act either helped to expand or maintain existing grant programs but offered little new funding.
Public health advocates have called for a sustained funding mechanism like the Ryan White HIV/AIDS program, which since 1990 has received more than $2 billion a year for medical care and support services for impoverished people living with HIV.
In the latest data from the Centers for Disease Control and Prevention, an estimated 70,000 people died from an overdose in 2017.
“The opioid epidemic is the size the AIDS epidemic at its peak,” Siegel said. “Tens of thousands of people are dying every year and we need to show the same commitment to opioids that we did to HIV.”
Congress failed to provide the CDC with funding to conduct research on gun violence and several healthcare providers filled the gap by starting their own initiatives.
In April, Kaiser Permanente invested $2 million to research gun violence, an amount nearly equal to the $2.6 million the CDC allocated to research gun violence in 1996. It was that year the Dickey Amendment passed, essentially banning federal funding to research the topic.
While Congress agreed to include a provision within the omnibus funding bill in March to clarify that the CDC was not barred from researching gun violence, the legislation did not appropriate money for the agency to conduct that work. In July, the House Appropriations Committee rejected a proposal to allocate $10 million to the CDC for gun violence research.
The Fourth National Climate Assessment, released in late November, found the effects of climate change are already taking a toll on human health, with increases in extreme weather events such as wildfires and hurricanes, a rise in infectious diseases transmitted by insects, and eroding water and air quality. Those problems are all projected to increase mortality and strain the health system.
Trump denied the conclusions found in the report, saying “I don’t believe it.” His administration has actively sought to roll back environmental protections to limit fossil fuel emissions from coal power plants, do away with clean water rules to protect waterways and wetlands, and eliminate vehicle fuel emission standards, to name a few.
The issue of climate change has been a particular vexing one for providers, as studies have shown the nation’s healthcare system alone is the world’s seventh-largest producer of carbon dioxide.
The year saw a growing number of health systems and hospitals respond by seeking to decrease their environmental footprint by investing in efforts to be more efficient in their water and energy use, while creating positions such as chief sustainability officers. In California, the largest systems in the state formed a healthcare climate alliance in August to lobby for regulations and laws that addressed climate change.
Ultimately, Castrucci said making progress on any of the major public health concerns came down to a matter of political will. He felt such an effort would ultimately require the kind of resources to successfully lobby for better health in the same way industries have lobbied for years on issues that have been detrimental to health.
“Alcohol has a lobby, soda has a lobby, guns have a lobby,” Castrucci said. “They’re all really well funded. Where’s the health lobby?”