Background
Public health should promote and protect the health of people and the communities in which they live, learn, work, and play. Strategies to improve the public’s health are multifaceted and involve multiple entities. This includes federal and state governments, health providers, faith- and community-based organizations, and individuals.
From a public health perspective, prevention is always preferable to treatment and cure. However, not all individuals have access to preventive health services, and not everything is preventable.
Persisting cost barriers to the use of preventive and screening services may result in more expenditures by Medicare. Preventable conditions may later emerge and require expensive treatments. These cost barriers do not aid in the promotion of public health.
Strategies to protect and promote public health include preventing disease and disability; monitoring and containing communicable disease outbreaks; improving health through sound nutrition; access to nutritious food, exercise, and healthy behaviors; ensuring air and water quality and food safety; preventing injuries and violence; and ensuring access to safe and stable affordable housing.
Older Americans underuse preventive services, such as screenings. In addition, there are significant racial and ethnic disparities in their use. These disparities persist regardless of income and health insurance status. Screening for HIV and sexually transmitted diseases is critical for older adults. It is estimated that nearly half of individuals living with HIV are age 50 and older.
The Affordable Care Act (ACAThe ACA—the shortened abbreviation for the Patient Protection and Affordable Care Act— is comprehensive health care reform legislation enacted by Congress and signed into law on March 23, 2010. ) eliminated cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. for most private and publicly funded preventive and screening services. However, some cost barriers to preventive care still exist. These include when services are miscoded or reclassified as diagnostic if and when providers discover a health problem.
And despite near-universal coverage by Medicare for those at or above age 65, Medicare beneficiaries face cost barriers as well. Medicare beneficiaries who receive certain recommended vaccines through Medicare Part D (the prescription drug program) are exposed to cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services.. Beneficiaries can also be exposed to cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. for an exempt screening if the service is reclassified as a diagnostic service when an abnormality is found. For example, under current Medicare law, a routine screening colonoscopy does not require cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services.. But if a polyp is found, the screening is recharacterized as a diagnostic test and cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. is then required. Finally, Medicare beneficiaries can be required to pay cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. (but not deductibles) for services associated with the receipt of a screening service, such as charges for anesthesia given during a routine screening colonoscopy.
The ACAThe ACA—the shortened abbreviation for the Patient Protection and Affordable Care Act— is comprehensive health care reform legislation enacted by Congress and signed into law on March 23, 2010. contains provisions that require certain federal agencies to implement a broad range of public health activities, especially with respect to prevention. They include:
- conducting a national public-private campaign aimed at raising awareness of activities that prevent chronic disease and promote health;
- maintaining a website with evidence-based information on health promotion and disease prevention, and an online tool for individuals to determine their risk for specific diseases and offer customized advice;
- providing guidance to states and health care providers regarding prevention and obesity-related services available to Medicaid beneficiaries;
- developing a plan promoting healthy lifestyles and self-management of chronic diseases for Medicare beneficiaries; and
- establishing a council for national prevention, health promotion, and public health to develop a national health prevention and promotion strategy and make recommendations to the president and Congress about pressing health issues.
The ACAThe ACA—the shortened abbreviation for the Patient Protection and Affordable Care Act— is comprehensive health care reform legislation enacted by Congress and signed into law on March 23, 2010. requires the Centers for Disease Control and Prevention to:
- establish and implement a science-based national media campaign on health promotion and disease prevention, and
- fund state and local pilot programs to improve the health of people age 55–64 through community-based public health interventions.
The ACAThe ACA—the shortened abbreviation for the Patient Protection and Affordable Care Act— is comprehensive health care reform legislation enacted by Congress and signed into law on March 23, 2010. also required the Government Accountability Office to conduct a study on how often Medicare beneficiaries age 65 and older receive recommended vaccines covered under Medicare Part D and make recommendations for increasing immunization rates among Medicare beneficiaries.
Additional public health provisions of the ACAThe ACA—the shortened abbreviation for the Patient Protection and Affordable Care Act— is comprehensive health care reform legislation enacted by Congress and signed into law on March 23, 2010. include:
- mandating investments in state, territorial, and local public health infrastructure;
- providing grants to implement recommended services;
- eliminating cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. for certain preventive services and health screenings in Medicare and private health insurance;
- providing enhanced federal funding for states that choose to eliminate Medicaid cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. for certain preventive services—including screenings;
- creating Community Transformation Grants to promote individual and community health and reduce disparities;
- establishing a Prevention and Public Health Fund designed to expand and sustain the infrastructure needed to prevent disease, detect it early, and manage conditions before they become severe;
- increasing the national investment in prevention and public health, to improve health, and to enhance health care quality;
- creating a demonstration program that will make grants available to state Medicaid programs to test the use of evidence-based incentives for Medicaid beneficiaries to prevent chronic diseases; and
- requiring restaurants, retail food establishments, and vending machine operations with 20 or more locations to post calorie content on menus and menu boards and to offer accessible nutritional information to customers.
Annual wellness visits for Medicare beneficiaries that include personalized prevention plans were also implemented as part of the health reform law.
Climate change and public health: Climate change has led to more extreme-weather days, increased number and intensity of natural disasters, and increased infectious diseases. Older adults, people with disabilities, people of color, people with low incomes, and people with chronic illnesses bear the greatest burden of disease and death related to climate change. Extremely hot and cold days, which are increasing because of climate change, can be lift-threatening for older adults. Older adults and people with disabilities also face greater challenges in evacuating safely during a natural disaster (see also Disaster Planning and Recovery).
Crisis standards of care: In 2020, the COVID-19 pandemic caused critical shortages of medical supplies and care. Under circumstances like these, doctors and hospitals are forced to decide who gets potentially lifesaving treatment and who does not.
The 2020 pandemic revealed the critical role and responsibility policymakers have to plan and implement strategies to do everything possible to avoid the emergence of shortages when there are severe outbreaks of highly contagious diseases such as COVID-19.
Some organizations, states, and federal agencies have anticipated challenges like these and developed resources and guides for hospitals and health systems. For example, in 2015, the New York Department of Health released a report on the logistical, ethical, and legal issues of allocating ventilators during a pandemic-created shortage. Federal health agencies, including the Department of Veterans Affairs and Department of Health and Human Services, have also published guidance that includes approaches for allocation of scarce resources during a pandemic.
These guidelines typically employ a utilitarian approach. They seek to maximize overall health by directing care toward those most likely to receive the greatest benefit from it. If a hospital had only one ventilator, for example, it would go to the patient who is more likely to survive. It would not go to whichever patient was first admitted, and it would not be assigned via a lottery system. The guidelines also often prioritize the health of front-line health care workers to maximize the number of lives saved.
The process for developing guidelines for these profoundly difficult decisions requires a thorough ethical, clinical, and legal analysis. The process should be transparent and include genuine public outreach, education, and engagement in order to establish public trust. It is equally critical that the guidelines include protection for groups that often face discrimination including older persons, persons with disabilities, those with lower incomes, the uninsured, and other historically disadvantaged racial and ethnic groups. There are already racial, ethnic, and socioeconomic disparities in care. Therefore these protections are essential in ensuring no group is disproportionately harmed by these policies and guidelines. Transparency is important in the logic, reasoning, and analysis behind the guidelines. Finally, the guidelines should be updated and revised in line with advances in clinical knowledge and changes in societal norms. Feedback from clinicians and the public is also essential.
The Office for Civil Rights at the Department of Health and Human Services, which enforces several anti-discrimination laws in health care facilities that receive federal funding, issued a bulletin emphasizing the need for protection against discrimination for certain groups. This included older adults and those with disabilities. Specifically, it said medical care should not be denied based on stereotypes, assessments of quality of life, or judgments about a person’s relative “worth” due to age or the presence or absence of disabilities.
PROMOTING PUBLIC HEALTH: Policy
PROMOTING PUBLIC HEALTH: Policy
Public health promotion
All levels of government should be prepared to adequately respond to public health crises.
All levels of government should conduct activities designed to protect, improve, and maintain public health. These should include:
- financing preventive services and health promotion, and
- funding and supporting community-based strategies to address the social determinants of health.
Other activities should include:
- tracking and educating the public about preventable injuries, including the impact of gun violence and its ramifications on public health;
- adequately funding preventive health services and health-promotion programs (e.g., nutritional screening and counseling, exercise and weight-control programs, and drug-, alcohol-, and tobacco-addiction treatment programs) and preventive health-education programs for people most in need;
- educating individuals about risk factors for prevalent health conditions, behaviors that reduce health risks (e.g., exercise and nutrition), and the importance of preventive care (e.g., mammography, cancer screening, early immunizations for children, and influenza and pneumococcal pneumonia immunizations for older Americans);
- identifying health-promoting behaviors, including the ways in which such behaviors are linked to health improvements and the costs and benefits associated with health-promoting behaviors;
- supporting outreach and education about the value of engaging in healthy behaviors, with information targeted to consumers, family caregivers People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. , and employers; and
- identifying ways to support the implementation of evidence-based, nondiscriminatory workplace wellness programs by small employers.
Research should be conducted on health-promotion behaviors. The public should be educated about them.
Public health research and infrastructure should be adequately funded at all levels of government.
Adequate public health funding must include resources for research and activities related to population health disease prevention and intervention, health promotion and education, health equity, and emergency preparedness and response.
Community-based strategies to address the social determinants of health should be promoted.
Federal, state, and local governments should make adequate funding available to support their respective public health infrastructures.
All levels of government and the private sector should take affirmative and sustained actions to address the drivers of inequities in health and health outcomes.
Personal responsibility
Officials at all levels of government should help people fulfill their personal responsibility to protect their health by taking advantage of health-education opportunities and affordable and appropriate preventive health measures.
Policymakers at all levels of government should collaborate to develop, fund, implement, and evaluate strategies to protect and improve the public’s health.
They should support policies and implement programs that promote healthy behaviors.
Policymakers should support the collection and analysis of public health data. They should also strengthen state and local capacity to deliver public health services.
Scientific knowledge should be applied to policymaking. Comprehensive public health data should be collected, analyzed, interpreted, and disseminated to monitor and improve public health. Specific data on demographics—including race, ethnicity, and language—and geography can help inform efforts to reduce health disparities.
Sound public health strategies for protection and promotion, disease prevention, and intervention should be based on evidence and should have proven efficacy. Costs and benefits should be considered but should not be determinative. Policymakers should develop infrastructure such as provider laboratory and surveillance capacity and provider education. In addition, federal, state, and local strategies to improve the public’s health should focus on broad-based community interventions that promote health and reduce health disparities.
Governments should call national attention to public health issues. They should promote the application of scientific knowledge to policymaking and support the collection and analysis of public health data. State and local capacity to deliver public health services should be strengthened.
Federal, state, and local governments should provide incentives for people to engage in those behaviors and strengthen the physical infrastructure that supports such health-promoting behaviors.
Public health workforce
All levels of government should fund public health workforce development, including strategies to ensure workforce diversity.
Ensuring adequate funding
The federal government should adequately fund the Prevention and Public Health Fund.
All levels of government should increase funding for public health activities. Funding should focus on research, the implementation of public health prevention and promotion, the enforcement of environmental and safety standards, and public and professional health education.
All levels of government should direct sufficient financial and technological resources toward:
- solving environmental problems and working cooperatively with the private sector to address environmental concerns;
- the timely development and manufacture of safe, effective vaccines (during vaccine shortages, the federal and state governments should not adopt policies that allocate vaccines solely on the basis of age);
- research into effective strategies to protect the public from biological attacks; and
- ensuring key public- and private-sector health care personnel are adequately prepared to respond to public health crises relevant to their areas of practice.
Eliminating disparities in the use of preventive and screening services
Disparities in the use of prevention and screening in public- and private health insurance programs should be identified. Strategies to eliminate such disparities should be developed and implemented.
Medicaid cost-sharing for preventive services and screenings
State Medicaid programs should make certain preventive and screening services available to beneficiaries without any cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. obligations.
Medicare cost-sharing for preventive services and screenings
The federal government should take the lead in addressing medical coding issues that result in individuals wrongfully being charged for preventive and screening services that are supposed to be free.
The practice of recoding a routine screen when an abnormality is found as diagnostic instead, for which cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. then applies, should be eliminated.
Providers should be required to alert beneficiaries of any cost-sharingThe share of insurance-covered costs that a person pays out of pocket, including deductibles, coinsurance, and copayments. It does not include premiums, balance billing amounts for non-network providers, or the cost of non-covered services. obligations they might incur for screenings rated A or B by the Preventive Services Task Force. That information should be provided before the screening.
Pollution control
Public agencies should take specific and effective steps to control all forms of pollution (including biological and chemical agents) that threaten health, safety, and quality of life.
Coordinated emergency and crisis planning
Policymakers should collaborate to identify, develop, fund, and implement timely, effective response plans for national, state, and local public health crises.
Governments should develop strategies designed to meet the health care needs of people affected by catastrophic events (e.g., hurricanes, avian influenza, West Nile virus, and COVID-19). Such strategies should, at a minimum, finance health care for the uninsured for a reasonable period of time. They should ensure the availability and accessibility of needed services and equipment. The federal government should require all states to develop comprehensive disaster plans designed to adequately protect the health and welfare of vulnerable populations such as older adults and people with disabilities during a public health crisis.
In the case of a national public health emergency, there should be a national response plan which includes acquiring and distributing necessary equipment and supplies. Federal and state governments should work cooperatively to address the emergency and avoid unnecessary competition for goods.
Crisis standards of care
Policymakers and health care administrators must conduct adequate emergency preparedness planning to avoid scarcity of medical equipment, supplies, and personnel that result in the need to make determinations of who gets care and who does not.
They should also develop guidelines for the allocation of scarce resources. The process should be transparent and include broad input and genuine public outreach, education, and engagement in order to establish public trust.
Transparency and Protection Against Discrimination in Crisis Management: If policymakers design guidelines for the allocation of scarce health resources in times of emergency, the guidelines must be transparent.
These guidelines must not discriminate against older persons, persons with disabilities, those with lower incomes, the uninsured, and individuals from other historically disadvantaged groups.
Decisions concerning whether an individual is a candidate for treatment must not be based on age, race, disability, income, or other nonclinical factors, but on an individualized clinical assessment of the patient and their circumstances using the best available objective medical evidence.
Research
Federal and state governments should support research that identifies the effects of health-promoting behaviors on public health, for example, exercise on cardiovascular and cognitive health. They should fund cost-benefit research on health-promoting behaviors regarding both the public and private sectors such as the cost to employers of workers’ inactivity.
Communicable diseases
Health care providers and individuals should be educated about behavioral risk factors for contracting and spreading serious communicable diseases. These include diseases such as tuberculosis, hepatitis, HIV/AIDS, and COVID-19. Health providers should recognize the importance of taking sexual histories and discussing HIV/STD prevention with patients age 50 and older. Programs should teach all individuals who know or have reason to believe that they may be infected to protect others from infection. They should advise those whom they know to be at risk to seek testing. The outcome of such tests must be confidential, consistent with public health responsibilities, and subject to the requirements of confidentiality standards.
Health care providers, businesses, schools, organizations, and individuals should ensure that they are educated about behavioral risk factors for contracting and spreading serious communicable diseases.
Vaccines
All levels of government should:
- direct sufficient financial and technological resources toward the timely development and manufacture of safe, effective, and affordable vaccines; and
- provide funding to ensure that key public- and private-sector health care personnel are adequately prepared to respond to public health crises relevant to their areas of practice.
Federal and state governments should:
- develop transparent, nondiscriminatory, evidence-based guidelines for vaccine allocation that maximize overall public health and protect those at highest risk of harm during vaccine shortages; and
- adopt policies that ensure that vaccines have appropriate clinical evidence of safety and efficacy, are allocated equitably, and are widely available.
Public officials and other stakeholders should employ targeted, evidence-based outreach strategies to build public trust and help individuals make informed decisions about FDA-approved vaccines.
Smoking bans
Federal and state governments should enact legislation banning smoking in nonresidential public buildings, on public transportation, and in restaurants.
Preference for allocating government revenues from tobacco company settlements should be given to programs designed to improve public health, including Medicaid and Medicare, antismoking and smoking-cessation programs, and efforts to expand access to long-term care and other health care services. Tobacco settlement funds should not replace existing federal or state funding in these areas.
To promote government accountability, states should develop a public process for deciding how tobacco settlement funds should be spent. Those expenditures should be disclosed annually. The information should be brought to the attention of the general public.
State governments should ensure that their public health infrastructures are adequate, strong, and sustainable over the long term before using tobacco settlement funds to balance state budgets.
Public health effects of climate change and extreme weather conditions
Policymakers should mitigate the immediate effects of climate change events on the health of older adults and other vulnerable populations. This includes ensuring affordable access to heating and cooling, particularly during extreme temperature days, which are more common because of climate change (see also Sustainable Energy).
During extreme weather or climate-related events, policymakers should:
- provide immediate assistance to vulnerable populations, particularly those with chronic health conditions that are exacerbated by climate change; and
- address the needs of people with disabilities, who may have greater difficulty evacuating or otherwise seeking aid during an emergency (see also Assistance Programs).
Policymakers should prevent, plan for, and mitigate the environmental, socioeconomic, and infrastructural impacts of climate change on the health of older adults and other vulnerable populations.