Public Health Engagement Aff Notes

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The U.S. should focus on improving its own public health systems first—they clearly don’t have the knowledge or resources necessary to be expending to China

Woolf and Aron '13 (Steven H. Woolf and Laudon Aron, Editors on the Committee on Population for the National Research Council and U.S. Institute of Medicine, "U.S. Health in International Perspective: Shorter Lives, Poorer Health", National Research Council and Institute of Medicine,, CL)

One explanation for the health disadvantage of the United States relative to other high-income countries might be deficiencies in health services. Although the United States is renowned for its leadership in biomedical research, its cutting-edge medical technology, and its hospitals and specialists, problems with ensuring Americans’ access to the system and providing quality care have been a long-standing concern of policy makers and the public (Berwick et al., 2008; Brook, 2011b; Fineberg, 2012). Higher mortality rates from diseases, and even from transportationrelated injuries and homicides, may be traceable in part to failings in the health care system. The United States stands out from many other countries in not offering universal health insurance coverage. In 2010, 50 million people (16 percent of the U.S. population) were uninsured (DeNavas-Walt et al., 2011). Access to health care services, particularly in rural and frontier communities or disadvantaged urban centers, is often limited. The United States has a relatively weak foundation for primary care and a shortage of family physicians (American Academy of Family Physicians, 2009; Grumbach et al., 2009; Macinko et al., 2007; Sandy et al., 2009). Many Americans rely on emergency departments for acute, chronic, and even preventive care (Institute of Medicine, 2007a; Schoen et al., 2009b, 2011). Cost sharing is common in the United States, and high out-of-pocket expenses make health care services, pharmaceuticals, and medical supplies increasingly unaffordable (Commonwealth Fund Commission on a High Performance System, 2011; Karaca-Mandic et al., 2012). In 2011, one-third of American households reported problems paying medical bills (Cohen et al., 2012), a problem that seems to have worsened in recent years (Himmelstein et al., 2009). Health insurance premiums are consuming an increasing proportion of U.S. household income (Commonwealth Fund Commission on a High Performance System, 2011). Apart from challenges with access, many Americans do not experience optimal quality when they do receive medical care (Agency for Healthcare Research and Quality, 2012), a problem that health policy leaders, service providers, and researchers have been trying to solve for many years (Brook, 2011a; Fineberg, 2012; Institute of Medicine, 2001). In the United States, health care delivery (and financing) is deeply fragmented across thousands of health systems and payers and across government (e.g., Medicare and Medicaid) and the private sector, creating inefficiencies and coordination problems that may be less prevalent in countries with more centralized national health systems. As a result, U.S. patients do not always receive the care they need (and sometimes receive care they do not need): one study estimated that Americans receive only 50 percent of recommended health care services (McGlynn et al., 2003). Could some or all of these problems explain the U.S. health disadvantage relative to other high-income countries? This chapter reviews this question: it explores whether systems of care are associated with adverse health outcomes, whether there is evidence of inferior system characteristics in the United States relative to other countries, and whether such deficiencies could explain the findings delineated in Part I of the report.

The panel defines “health systems” broadly, to encompass the full continuum between public health (population-based services) and medical care (delivered to individual patients). As outlined in previous Institute of Medicine reports (e.g., 2011e), health systems involve far more than hospitals and physicians, whose work often focuses on tertiary prevention (averting complications among patients with known disease). Both public health and clinical medicine are also concerned with primary and secondary prevention.1 The health of a population also depends on other public health services and policies aimed at safeguarding the public from health and injury risks (Institute of Medicine, 2011d, 2011e, 2012) and attending to the needs of people with mental illness (Aron et al., 2009). There is mounting evidence that chronic illness care requires better integration of professions and institutions to help patients manage their conditions, and that health care systems built on an acute, episodic model of care are ill equipped to meet the longer-term and fluctuating needs of people with chronic illnesses. Wagner and colleagues (1996) were among the first to document the importance of coordination in managing chronic illnesses. Many countries differ from the United States because public health and medical care services are embedded in a centralized health system and social and health care policies are more integrated than they are in the United States (Phillips, 2012). The panel believes that the totality of this system, not just the health care component, must be examined to explore the reasons for differences in health status across populations. For example, a country may excel at offering colonoscopy screening, but ancillary support systems may be lacking to inform patients of abnormal results or ensure that they understand and know what to do next. Hospital care for a specific disease may be exemplary, but discharged patients may experience delayed complications because they lack coverage, access to facilities, transportation, or money for out-of-pocket expenses, and those with language or cultural barriers may not understand the instructions. The health of a population is influenced not only by health care providers and public health agencies but also by the larger public health system, broadly defined.2

No money

Woolf and Aron '13 (Steven H. Woolf and Laudon Aron, Editors on the Committee on Population for the National Research Council and U.S. Institute of Medicine, "U.S. Health in International Perspective: Shorter Lives, Poorer Health", National Research Council and Institute of Medicine,, CL)

The familiar adage to “follow the money” is a reminder that a society’s policy priorities are often reflected in budget decisions. The panel’s review of data on the U.S. health disadvantage and its potential causes shows that the United States often spends less per capita in many of the areas in which its performance is lagging, with the obvious exception of health care. Levels of spending should be interpreted with caution because they say little about the efficiency or effectiveness of programs, but the spending patterns of the United States stand in contrast to those of other high-income countries with better health outcomes. Examples include early childhood education, family and children’s services, education, and public health. • Early childhood education: In 2007, the United States spent only 0.3 percent of its GDP on formal preschool programs (for children aged 3-5 years), less than that of seven peer countries and even some emerging economies in Eastern Europe (OECD, 2012i). • Family and children’s services: Total public spending by the United States on services for families and young children places the United States last among the 13 peer countries studied. In 2004, the most recent year reported by the OECD, the United States devoted only 0.78 percent of GDP to public services for families and young children, whereas Nordic countries spent approximately 4 percent (OECD, 2006). Only Korea ranked lower than the United States on the proportion of its economy devoted to public services for families and young children. • Public health: According to many analyses, public health is systematically underfunded in the United States (Institute of Medicine, 2012; Mays and Smith, 2011), for a variety of reasons (Hemenway, 2010), but valid data for international comparisons are lacking. The OECD does measure the proportion of public expenditures devoted to health and to public health, but classification schemes are too variable by country to draw meaningful inferences. • Social services: Compared with other countries, the United States spends less on social programs, subsidies, and income transfers than do other countries (see Figure 8-5). As noted above, U.S. spending on social services (13.3 percent of GDP) was less than the OECD average (16.9 percent) and that of all 30 countries except Ireland, Korea, Mexico, New Zealand, and the Slovak Republic (Bradley et al., 2011). A recent report found that the United States spent less on public social protection (as a percentage of GDP) than any peer country but Australia and less than some emerging economies, including Russia and Brazil (International Labour Office, 2011).


Trades off with efficiency—often comes at the expense of the people

Mankiw '10 (Greg Mankiw, Professor of Economics at Harvard University, "Healthcare, Tradeoffs, and the Road Ahead", Greg Mankiw's Blog: Random Observations for Students of Economics, March 22,, CL)

Well, it appears certain that the healthcare reform bill will become law. One thing I have been struck by in watching this debate is how strident it has been, among both proponents and opponents of the legislation. As a weak-willed eclectic, I can see arguments on both sides. Life is full of tradeoffs, and so most issues strike me as involving shades of grey rather than being black and white. As a result, I find it hard to envision the people I disagree with as demons. Arthur Okun said the big tradeoff in economics is between equality and efficiency. The health reform bill offers more equality (expanded insurance, more redistribution) and less efficiency (higher marginal tax rates). Whether you think this is a good or bad choice to make, it should not be hard to see the other point of view. I like to think of the big tradeoff as being between community and liberty. From this perspective, the health reform bill offers more community (all Americans get health insurance, regulated by a centralized authority) and less liberty (insurance mandates, higher taxes). Once again, regardless of whether you are more communitarian or libertarian, a reasonable person should be able to understand the opposite vantagepoint. In the end, while I understood the arguments in favor of the bill, I could not support it. In part, that is because I am generally more of a libertarian than a communitarian. In addition, I could not help but fear that the legislation will add to the fiscal burden we are leaving to future generations. Some economists (such as my Harvard colleague David Cutler) think there are great cost savings in the bill. I hope he is right, but I am skeptical. Some people say the Congressional Budget Office gave the legislation a clean bill of health regarding its fiscal impact. I believe that is completely wrong, for several reasons (click here, here, and here). My judgment is that this health bill adds significantly to our long-term fiscal problems. The Obama administration's political philosophy is more egalitarian and more communitarian than mine. Their spending programs require much higher taxes than we have now and, indeed, much higher taxes than they have had the temerity to propose. Here is the question I have been wondering about: How long can the President wait before he comes clean with the American people and explains how high taxes needs to rise to pay for his vision of government?


China’s health care system is overwhelmed and unsustainable

Wharton '13 (Knowledge at Wharton, "Ticking Time Bombs’: China’s Health Care System Faces Issues of Access, Quality and Cost", University of Pennsylvania, June 26,, CL)

China’s health care system is ailing, and the prognosis for a cure in the near future is not good. Wharton health care management professor Lawton R. Burns recently returned from Beijing, where he and Gordon G. Liu, professor of economics at Peking University’s Guanghua School of Management, co-taught a four-day course on China’s health care system. The course, attended by 20 Wharton students and 20 Peking University students, looked at such topics as quality and availability of care, the disparity between rural and urban health care, corruption in the delivery system, medical training and the needs of a growing elderly population. Underlying some of China’s most basic health care challenges is the “wide but shallow distribution of health insurance,” says Burns. Recent reforms have extended health care to 95% of the population — most of whom have never had insurance before — a development that has caused serious strains on the delivery system. Now that consumers have access, “everyone wants to go to the major academic health centers, which means there are enormous lines starting early in the morning to get in and see a specialist,” says Burns, who toured several health care facilities during his teaching week. Not everyone gets through the line, however, and people who do get in don’t always get the results they want. “People expect good care now, and when they don’t receive it, they sometimes blame the doctors,” notes Burns, adding that there have been cases of medical personnel physically attacked by dissatisfied patients. For the Chinese government, the issue is cost: How do you fund health care for a new group of insured people, in both rural and urban areas, who had until recently been lacking coverage for even the most basic health care needs? “There is always a trade-off between increasing access to health care, and funding that access. It has to do with the ‘Iron Triangle,'” says Burns, referring to a phrase that describes the three main cornerstones of health care: access, cost and quality. The difficulty comes when regulators try to improve all three, or even two, at once. “If you increase access, you increase cost. So how do you balance the two,” especially when the expectations of newly insured consumers are rising so quickly? More Money, More Prestige: The problem of access to quality care is especially acute in rural areas of China. “Physicians find big disparities in terms of income, status and access to technology in the countryside versus the city,” says Burns, noting that doctors naturally tend to gravitate to the research opportunities, higher salaries and clearer career paths offered by big urban medical facilities. “Why would a doctor move from a class three urban hospital to the lower pay of a class one or two hospital in a rural area? Doctors lose prestige and money by going outside the cities.” Indeed, with so much investment and technology targeted to urban medical centers — which then attract the best doctors and the highest-paying patients — meaningful redistribution of physicians is difficult to bring about. Burns does suggest one option: Provide incentives to medical students through a national rural health service program that encourages them to practice in rural areas for the first two or three years after graduation. The program could target new doctors who come from the countryside and might be more inclined to return there to work. China’s aging population presents the health care system with another challenge, and one that is likely to get worse, as it will in many other countries facing a similar demographic shift. According to figures from the United Nations, almost one third of China’s population, or 438 million, will be over 60 by 2050, more than double the current number of 178 million. “In China, the percentage of the population that is really elderly is 8% to 9%, but it is growing very quickly because of the one-child policy,” says Burns. Often referred to as “the 4-2-1 problem,” the policy has meant that one child has to support two parents and four grandparents. Meanwhile, no organized long-term care or home health care systems exist despite the increasing number of people who will need these kinds of services. While China’s aging problem is significant, France and Japan face an even bigger problem in this area because they have more restrictive immigration policies, according to Burns. “In the U.S., what keeps our aging problem under control is the fact that we allow in immigrants who work, pay taxes and support the elderly, thereby keeping our age-dependent ratio lower than that in more restrictive countries.” While the U.S. has a positive and fairly high rate of immigration, China has a negative rate — meaning that more people leave the country than enter. Another “ticking time bomb” in China is the middle-aged Chinese male who works long hours in often stressful conditions, says Burns. “Many suffer from hypertension and diabetes, and 30% to 50% of them smoke. All the Western diseases are showing up in China — the most popular Western restaurant now is Kentucky Fried Chicken — which means the country will have a growing problem with early onsets of chronic illnesses, comparable to the U.S.” Health care reform in China is further impeded by the fact that the heads of many Chinese medical centers tend to be political appointees rather than professionally trained managers, Burns says, which results in serious performance and governance issues. Nor does the country’s medical education system offer hospital administration programs. Add to that the existence of widespread corruption. “The government controls the prices on low-cost items to make them widely accessible and available,” says Burns. “But because that hurts the hospitals’ bottom line, the government lets the hospitals charge much higher prices on high-tech equipment and offer more expensive drugs, devices and procedures.” Patients end up paying the price. Indeed, a significant portion of health care spending in China — 50% — is still out of pocket, Burns adds. Finally, there are kickbacks at various junctures in the delivery process: Hospitals, for example, get kickbacks from drug and device companies, and hospital executives give a portion of these kickbacks to their doctors. Burns acknowledges that the U.S. health care system is corrupt in some ways as well, “but not nearly to the extent that it is in China. There are conflicts of interest in the U.S., and there are hospital executives giving kickbacks to doctors. But those people go to jail. There is nobody going to jail in China.” Other parallels exist to varying degrees between China and the U.S. when it comes to the health care challenge. Even as the Chinese government has expanded health care coverage, so has the Obama administration expanded coverage to an additional 30 million new people, “many of whom will be hard pressed to find a primary care physician,” says Burns. Cost is an issue as well. If you “look at how Obamacare was pitched, administration officials said part of it will be paid for by taxing the insurance and medical device industries and reducing payments to providers,” says Burns. “Officials also said that some of the savings will come from employee wellness programs, efficiencies in delivery and so forth. Yet there is little evidence that wellness programs and restructured delivery systems save money.” Neither country has had success providing coordinated health care — such as pairing patients who have chronic diseases with nurses and other care managers who can help these patients develop better health habits. “Most of the experiments in coordinated care have not worked in the U.S., nor have they saved money,” says Burns. All these challenges will cause problems for the provincial and central governments in China that must foot the health care bill, Burns adds, noting that historically, China and also India — which both have much bigger populations than the U.S. — have spent very little of their gross domestic product on these services. As for private health insurance, a number of Western insurance companies have been in China for several years to study this option. But so far, “they have developed insurance only for expats,” Burns says. “The local population does not have much of a private health care insurance industry.” Nor have the few private sector hospital chains in China proven very successful, “although the government is going to encourage them because it needs more supply to meet demand.” Part of the problem is the lack of qualified doctors to treat the newly insured. “There is an insufficient supply of allopathic-trained physicians — those trained in the Western model as opposed to the indigenous traditional medicine model,” says Burns. Both China and India each have their traditional providers, “although there is no evidence they provide the same kind of care as allopathic doctors.” Meanwhile, he adds, there is “a huge push to increase academic research and to institute higher and more uniform standards of training.” The course co-taught by Burns and Liu took shape after Burns had offered a similar course on health care in India and realized it could be duplicated in China. After further research and some negotiation, the two presented “China’s Healthcare System and Reform” for the first time in May 2012 and then again last March. In addition, Burns has edited a book coming out this summer based on the course in India and titled, India’s Healthcare Industry: Innovation in Delivery, Financing and Manufacturing. Several of the chapters were written by course presenters, teaching assistants and enrolled students. Burns says he plans to edit a similar book based on the course in Beijing.

Poor Framework

Institutional pluralism is the new framework for ensuring public health—aff is too exclusive

Long ’11 (William Long, Professor and Chair at the Sam Nunn School of International Affairs Georgia Institute of Technology, “Pandemics and Peace: Public Health Cooperation in Zones of Conflict", published June 2011)

In health, power has shifted from vertically organized governments and international agencies to horizontally linked coalitions or networks that also include private actors such as nongovernmental organizations, businesses, and philanthropies; a process of institutional pluralism driven by changing ideological and institutional preferences, technological advances, new sources of funding; and lower barriers to entry.54 These new amalgamations have been labeled global health alliances, global health partnerships, and global public-private partnerships." The three examples of public-private governance initiatives in infectious disease control examined in this study provide a basis for systematically exploring key questions regarding global health governance, and transnational problem-solving networks." Specifically, we want to know whether these experiments in transnational governance can collectively solve problems and effectively deliver the (public) goods. If so, we need to identify the factors that either are necessary or facilitate effective governance. In addition, we want to use these cases both to consider whether the authority wielded by these transnational networks is legitimate, defined in terms of democratic accountability, and specify the factors that enhance or impede their legitimacy. Detailed comparative analysis of the governance process in these three cases will generate useful insights for practitioners and researchable hypotheses for scholars. For practitioners and policymakers, generic insights can be tailored to their specific circumstances. For scholars and students, these cases may contribute to a better understanding of global governance, private-public partnerships, and transnational problem-solving networks by generating plausible hypotheses about the effectiveness, legitimacy, and origins of transnational networks for further inquiry.

Global public health policy needs to model a horizontal structure of aid—U.S. doesn’t spend enough to help others

Long ’11 (William Long, Professor and Chair at the Sam Nunn School of International Affairs Georgia Institute of Technology, “Pandemics and Peace: Public Health Cooperation in Zones of Conflict", published June 2011)

U.S. Government Programs

American domestic public health initiatives date to the early years of the republic and the nation's involvement in international public health began in the late 1800s with its participation in the first international sanitary conferences." During and soon after World War II, U.S. military and civilian agencies were often called on to assist in identifying and eradicating disease and fortifying international public health systems abroad. Support for over-seas public health systems has been part of the mission of the U.S. Agency for International Development (USAID) since its inception in 1961, for example, and the Centers for Disease Control and Prevention (CDC) has been active in the worldwide campaigns to eradicate infectious diseases, such as smallpox, since the 1960s. Today, U.S. global public health policy is a sprawling and complex enterprise. As of 2008, federal expenditures totaled about $9 billion allocated to eleven executive departments and agencies (plus five multiagency initiatives).12The U.S. government has programs in more than 100 countries, and fifteen congressional committees oversee its efforts.13 Core support for programs designed exclusively to strengthen international infectious disease surveillance and response, less than $100 million, constitutes about 1 percent of all U.S. government global health expenditures. This figure is inexact, however, because of the way American foreign assistance and global public health policies are characterized and how programs are structured. First, American support for global public health programs are categorized as serving several broad purposes.14 Because these purposes are complementary, it is not always clear which programs and expenditures fall in which category.L5

A second and even larger problem for determining the scope of U.S. efforts stems from the vertical rather than horizontal structure of America's global health policies. That is, American programs and funding are directed overwhelmingly toward particular diseases or themes rather than more general objectives such as strengthening overseas infectious disease control systems and coordinating these programs regionally and globally. Initiatives directed at specific diseases such as AIDS, malaria, tuberculosis, and influenza support some activities that improve infectious disease detection and response abroad through interagency funds transferred to programs that pursue this mission, and indirectly to the extent that their programs have system strengthening dimension. The amount of related interagency transfers varies from program to program and from one year to the next, as do the funds secured from private donors that augment U.S. infectious disease control programs abroad. Given these caveats, this chapter focuses on four programs shared by three federal departments that are explicitly aimed at improving the infectious disease detection and response capabilities of other nations and regions:" the Global Disease Detection Program operated by the CDC, which is part of the Department of Health and Human Services (HHS); the Field Epidemiology and Laboratory Training Program administered by the CDC with significant support from USAID;17 the Integrated Disease Surveillance and Response Program funded primarily by USAID and administered through CDC; and the Global Emerging Infections Surveillance and Response System of the U.S. Department of Defense. In addition to these four programs, USAID provides bilateral in-country support to public health programs in most of the more than 100 countries in which it operates, estimated at $14 million in 2006. These four programs, like U.S. support for global health programs generally, have long pedigrees. Each of the three federal departments or agencies directly responsible for infectious disease surveillance and response has supported foreign capacity building for many years. Within the last decade, however, these four programs have emerged as distinct policy initiatives.

Current U.S. policy needs to be modified so that its goals are measurable, better serves the target country, and are more long term

Long ’11 (William Long, Professor and Chair at the Sam Nunn School of International Affairs Georgia Institute of Technology, “Pandemics and Peace: Public Health Cooperation in Zones of Conflict", published June 2011, CL)

The failure to strengthen foreign capacity reflects a U.S. tendency to give money for treatment of particular diseases rather than invest for the long-term in public health infrastructure abroad. This approach persists despite the fact that viable health systems are key to curtailing the spread of infectious disease and improving the overall health of the recipient country. Investment in foreign public health capacity is limited for several reasons, but not particularly sound policy ones. First, demonstrating to appropriators and their constituents the direct, quantifiable impact of bolstering overseas public health systems is difficult. Lives not lost to disease, infections prevented by early detection, and pandemics avoided by rapid containment at the source are not as easily calculated or as compelling as immediate, measurable effects of a program that vaccinates or treats thousands or millions of patients for a particular illness. Secondly, system strengthening takes time to realize and appreciate. One analyst recommends a time frame of ten to fifteen years for measuring systemic health impacts. Policymakers in donor countries rarely think in terms beyond the current budget or electoral cycle, however, and are unlikely to make such patient investments. Third, because funding for global health primarily reflects the popular interests of the donor country (the United States) rather than the needs of the recipient country, American expenditures do not always align with the recipient’s national health plans or support the recipient’s overall public health and treatment infrastructure so as to maximize long-run return on foreign investment through a true partnership between donor and recipient. Finally, despite rhetoric to the contrary, U.S. policy still reflects too little appreciation of global interconnectedness and that U.S. interests defined in security, welfare, diplomatic, and humanitarian terms require significant investments abroad as well as at home. When it comes to sustained support of foreign capacity in infectious disease surveillance and response, our investment shortfalls leaves the United States and its global interests unnecessarily vulnerable and the country’s positive diplomatic influence insufficiently realized.

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