Clinical preventive services for older adults: the interface between personal health care and public health services.

Healthy aging must become a priority objective for both population and personal health services, and will require innovative prevention programming to span those systems. Uptake of essential clinical preventive services is currently suboptimal among adults, owing to a number of system- and office-based care barriers. To achieve maximum health results, prevention must be integrated across community and clinical settings. Many preventive services are portable, deliverable in either clinical or community settings. Capitalizing on that flexibility can improve uptake and health outcomes. Significant reductions in health disparities, mortality, and morbidity, along with decreases in health spending, are achievable through improved collaboration and synergy between population health and personal health systems.

How federalism shapes public health financing, policy, and program options.

In the United States, fiscal and functional federalism strongly shape public health policy and programs. Federalism has implications for public health practice: it molds financing and disbursement options, including funding formulas, which affect allocations and program goals, and shapes how funding decisions are operationalized in a political context. This article explores how American federalism, both fiscal and functional, structures public health funding, policy, and program options, investigating the effects of intergovernmental transfers on public health finance and programs.

Public health: a best buy for America.

Public health has considerable capacity to reduce the drag of health spending on our nation by preventing the leading causes of disease, death, and disability with cost-efficient, population-based interventions and innovative, boundary-spanning approaches that link clinical care and community prevention. Public health is uniquely able to identify the burdens of disease and analyze the best strategies for addressing them. A 3-pronged strategy can help assure the value needed from our public health investments. First, we must center our efforts on prevention. Second, we must optimize our public health investments to achieve the greatest value for our investment. Third, public health must collaborate with traditional and new partners on initiatives and in funding. How we finance public health is critical to maximizing public health's benefits and requires thoughtful analysis of how federal funding affects state and local health agencies' programming and how allocation drives choices and design, among other topics, as discussed in this special issue of the journal.

Resource and cost adjustment in the design of allocation funding formulas in public health programs.

CONTEXT: Multiple federal public health programs use funding formulas to allocate funds to states. OBJECTIVE: To characterize the effects of adjusting formula-based allocations for differences among states in the cost of implementing programs, the potential for generating in-state resources, and income disparities, which might be associated with disease risk. SETTING: Fifty US states and the District of Columbia. INTERVENTION: Formula-based funding allocations to states for 4 representative federal public health programs were adjusted using indicators of cost (average salaries), potential within-state revenues (per-capita income, the Federal Medical Assistance Percentage, per-capita aggregate home values), and income disparities (Theil index). MAIN OUTCOME: Percentage of allocation shifted by adjustment, the number of states and the percentage of US population living in states with a more than 20% increase or decrease in funding, maximum percentage increase or decrease in funding. RESULTS: Each adjustor had a comparable impact on allocations across the 4 program allocations examined. Approximately 2% to 8% of total allocations were shifted, with adjustments for variations in income disparity and housing values having the least and greatest effects, respectively. The salary cost and per-capita income adjustors were inversely correlated and had offsetting effects on allocations. With the exception of the housing values adjustment, fewer than 10 states had more than 20% increases or decreases in allocations, and less than 10% of the US population lived in such states. CONCLUSIONS: Selection of adjustors for formula-based funding allocations should consider the impacts of different adjustments, correlations between adjustors and other data elements in funding formulas, and the relationship of formula inputs to program objectives.

Reference allocations and use of a disparity measure to inform the design of allocation funding formulas in public health programs.

Funding formulas are commonly used by federal agencies to allocate program funds to states. As one approach to evaluating differences in allocations resulting from alternative formula calculations, we propose the use of a measure derived from the Gini index to summarize differences in allocations relative to 2 referent allocations: one based on equal per-capita funding across states and another based on equal funding per person living in poverty, which we define as the "proportionality of allocation" (PA). These referents reflect underlying values that often shape formula-based allocations for public health programs. The size of state populations serves as a general proxy for the amount of funding needed to support programs across states. While the size of state populations living in poverty is correlated with overall population size, allocations based on states' shares of the national population living in poverty reflect variations in funding need shaped by the association between poverty and multiple adverse health outcomes. The PA measure is a summary of the degree of dispersion in state-specific allocations relative to the referent allocations and provides a quick assessment of the impact of selecting alternative funding formula designs. We illustrate the PA values by adjusting a sample allocation, using various measures of the salary costs and in-state wealth, which might modulate states' needs for federal funding.

Funding formulas for public health allocations: federal and state strategies.

Public health funding formulas have received less scrutiny than those used in other government sectors, particularly health services and public health insurance. We surveyed states about their use of funding formulas for specific public health activities; sources of funding; formula attributes; formula development; and assessments of political and policy considerations. Results show that the use of funding formulas is positively correlated with the number of local health departments and with the percentage of public health funding provided by the federal government. States use a variety of allocative strategies but most commonly employ a "base-plus" distribution. Resulting distributions are more disproportionate than per capita or per-person-in-poverty allotments, an effect that increases as the proportion of total funding dedicated to equal minimum allotments increases.

Accomplishments in HIV prevention science: implications for stemming the epidemic.

The past two decades have witnessed substantial advances in the science of preventing HIV infection. Although important issues remain and there is a need for continuing research, arguably the biggest challenge in preventing HIV transmission is the full implementation of existing preventive interventions worldwide.

Analysis & commentary. The foundation that health reform lays for improved payment, care coordination, and prevention.

The Patient Protection and Affordable Care Act represents a major opportunity to achieve several key goals at once: improving disease prevention; reforming care delivery; and bending the cost curve of health spending while also realizing greater value for the dollars spent. Reform-based initiatives could produce major gains in a relatively short time. The U.S. Department of Health and Human Services should develop an action plan detailing how the programs that the health reform law sets into motion throughout various agencies can work synergistically. It should also detail how best practices in finance and payment, in the organization and delivery of care, and in prevention can be expanded nationally.

Chronic conditions account for rise in Medicare spending from 1987 to 2006.

Medicare beneficiaries' medical needs, and where beneficiaries undergo treatment, have changed dramatically over the past two decades. Twenty years ago, most spending growth was linked to intensive inpatient (hospital) services, chiefly for heart disease. Recently, much of the growth has been attributable to chronic conditions such as diabetes, arthritis, hypertension, and kidney disease. These conditions are chiefly treated not in hospitals but in outpatient settings and by patients at home with prescription drugs. Health reform must address changed health needs through evidence-based community prevention, care coordination, and support for patient self-management.