TO: Governor and Vice President-elect Mike Pence and members of the Presidential Transition Team
RE:  Frontline Health Leaders Urge Presidential Transition Team to Invest in Public Health

Dear Vice President-elect Pence and members of the Presidential Transition Team:

In our work as frontline health leaders in cities across America, we are confronted every day with an unfortunate truth: America’s approach to health is broken. We spend more on healthcare than any nation on Earth, and yet we rank 43rd in life expectancy and 57th in infant mortality.

We are not investing wisely, and our citizens are suffering the consequences. An epidemic of addiction and overdose – spiraling out of control. Millions of Americans with mental health conditions – left untreated. The emergency fund for responding to disease outbreaks and bioterrorist attacks – empty.       

A great nation requires a healthy people and productive workforce. It is about strong families and neighborhoods. It is about children who are set up for success. It is about a foundation for our economy and our public safety.

If we are to realize our aspiration to greatness, we need to change the way that we invest in health. We need to recognize that our health is shaped by where we live, work, and play – that our zip code is a better predictor of our health than our DNA. And we need to make the concomitant change to a system where, despite the fact that only 10 percent of what determines life-expectancy takes places within the four walls of a clinic, 97 percent of health spending goes to direct care delivered in hospitals.

The problem does not lie with the quality of this care; it is some of the world’s best. It lies, instead, with the inadequacy of our commitment to public health – with our failure to pay for the early interventions that would reduce the need for direct care down the line. We often talk about controlling health costs. This is the only way: with work that prevents health problems from arising in the first place. A commitment to fiscal responsibility is a commitment to public health.

This is not just a problem of health outcomes and costs; it is also a matter of national security. Lack of attention to our public health infrastructure makes us vulnerable to bioterrorism and to the threat of emerging diseases like Ebola, Zika, and multi-drug resistant tuberculosis.

As leaders of major cities’ health departments across the country, we urge the new Administration to consider the public health approaches highlighted below. Their adoption would improve Americans’ health; save the government valuable resources; and enhance our national security.

Opioid addiction and overdose

Drug overdoses kill more Americans than car crashes. An epidemic of opioid addiction has swept across the country. This epidemic knows no ideology or geography. In 2014, nearly 29,000 Americans died of an opioid overdose. This represents an extraordinary increase over previous years: between 2000 and 2014, the rate of death from opioid-related overdoses more than tripled. Because of illegally-trafficked Fentanyl, an opioid dozens of times stronger than heroin, the rate of overdose continues to rise today.

However a person becomes addicted – whether it’s through illicit drugs like heroin or prescribed medications like oxycodone – science tells us that addiction is a disease, treatment exists, and recovery is possible. Hundreds of scientific studies show that a combination of medication-assisted treatment and psychosocial care works. Yet, nationwide, only 11 percent of those with substance abuse disorders get the treatment that they need. We would not accept this for any other disease. This is not just unethical but costly and counterproductive. The World Health Organization estimates that for every $1 spent on treatment, society saves $12. Treatment also reduces the cost of incarceration and the rate of neighborhood crime.

We know how to treat addiction. We also know how to prevent overdose: with naloxone (also known as Narcan), an easily-administered antidote that can reverse an opioid overdose in a matter of seconds, and which has no serious side effects. Yet, local communities are being priced out of their ability to save lives because of the rising cost of naloxone.

We propose that the new Administration:

• Prioritize combatting opioid addiction and overdose in the first 100 days and ask all relevant federal agencies (ONDCP, HHS, DEA, DHS, etc.) to take part in comprehensive plan to reduce drug trafficking, stop opioid overprescribing, support diversionary programs for low-level drug offenders, and increase access to treatment;
• Work with manufacturers to reduce the price of naloxone so that all local communities can purchase it for their first-responders to save lives;
• Ensure that the Comprehensive Addiction Recovery Act – legislation to increase access to addiction treatment – is adequately funded;
• Directly fund local communities of greatest need, allowing cities and counties on the frontlines to innovate and take action;
• Appoint an ONDCP director with experience in public health and addiction treatment to ensure that addiction is addressed as the disease that it is.

Public health preparedness

It took Congress 233 days to provide resources to combat the spread of Zika in the United States. While it waited, the CDC was, paradoxically, only able to fund the nation’s response by taking Public Health Emergency Preparedness resources away from state and local health departments. Local health departments had to divert funding from other critical needs, such as the opioid epidemic, in order to prevent a generation of children from being born with severe brain damage.

The Public Health Emergency Response fund, established by the Congress during President Reagan’s first term, is empty. This poses a threat to the safety of the American people: it is a matter of national security, and an urgent one. A bioterrorist attack; a new outbreak of Ebola; bird flu or some other super-virulent strain of influenza; anthrax; MRSA; multi-drug resistant tuberculosis – the list goes on. Whatever the threat, the President needs to be able to direct funds to local public health responders immediately.

It is not only our emergency response infrastructure that requires attention; we also need to repair the infrastructure that keeps us safe in other ways that are just as important. It is said that public health saved your life today; you just don’t know it. This is the infrastructure that ensures we don’t get food poisoning; contains the spread of HIV and other infectious diseases; and could prevent another outbreak of measles. It is the quiet spadework that protects us from ever-present threats – but only if it is adequately funded. Despite the threat to our citizens’ health and implications for national security, funding for public health preparedness has been on the decline, with a 30 percent reduction over the last decade.

 We propose that the new Administration:

• Re-fill the empty Public Health Emergency Response fund and empower the CDC and local cities and counties to respond rapidly in times of disease outbreaks and bioterrorism threats;
• Restore funding to local city and county health departments for core public health services to prevent disease and ensure safety of our citizens;
• Empower local jurisdictions that are on the frontlines with maximal flexibility to target emerging threats through direct funding;
• Appoint a CDC Director with frontline public health work experience on the local level and deep knowledge of disaster response and preparedness.

Healthy babies and children

Protecting the life of our babies and children is first and foremost a moral imperative. It is also a financial imperative; intervening early to foster the healthy development of our youth and support young families saves the country resources that it would otherwise spend later on in health and educational costs. Family support and coaching visits to new and expecting mothers, for example, lead to fewer preterm births (which require costly NICU stays); a lower infant mortality rate; and, beyond childhood, higher high school graduation rates and fewer interactions with the criminal justice system.

All told, these support services save $5.70 for every $1 spent. Other early childhood programs have similarly large returns on investment. Lead abatement programs, for example, save between $17 and $221 per $1 spent.

We propose that the new Administration:

• Fund home visiting, family support, and coaching pilots in undeserved rural counties and urban areas for all at-risk pregnant women, improving the health of their children and saving the government money;
• Expand mental health screenings and behavioral health services – including tobacco cessation and addiction treatment – for pregnant and expecting mothers;
• Strengthen families and reduce the rate of unplanned pregnancy by expanding medically accurate, age-appropriate reproductive health education for adolescents and ensuring access to full reproductive care for girls and women;
• Enforce lead regulations and support abatement programs, particularly in economically disadvantaged communities.

Mental health

In America, “health” is too often synonymous with “physical health.” The exclusion of mental health from our conception of health has no basis, and its results are tragic: millions of Americans experience mental health problems but go without treatment. This is not simply an issue of health; untreated mental illness also reduces productivity and affects our national economy.

We propose that the new Administration:

• Enforce legally-mandated parity in mental and physical insurance coverage;
• Fund pilot programs to increase access to mental health services, such as telemedicine to provide access to mental health in rural and urban underserved communities; 24/7 behavioral health ERs; and mental health services in schools;
• Encourage Congress to pass the bipartisan Excellence in Mental Health Act, expanding the number of Certified Community Behavioral Health Clinics;
• Incentivize collaborative care – where mental health conditions and substance use disorders are treated together in a primary care setting – through changes to Medicaid/Medicare reimbursement and through eliminating senseless rules like that which prevents same-day billing for primary care and mental health services;
• Enable cities and counties to receive federal funds directly, allowing for community-based innovations that will have maximal impact.

Violence

As doctors and public health officials, we see how violence directly impacts health. We also see the impact of a valuable tool that can complement law enforcement and keep Americans safe: to view violence as a disease. Like an infectious disease, violent events often cluster, with violence begetting violence, spreading from person to person. Like an infectious disease, treatment is possible. By interrupting the cycle of violence, we save lives, prevent injury, and preempt costly hospital visits.

This public health approach to violence has been proved effective. When implemented in American cities, it has effected double-digit reductions – up to 73 percent – in both shootings and killings. Every shooting costs society at least $100,000. If it results in a spinal cord injury, the amount is more than $500,000. A homicide results in at least $1 million in lost economic costs. Preventing violence saves lives and saves money.   

We propose that the new Administration:

• Save lives, reduce health care costs, and make Americans safer by encouraging the nationwide adoption of public health approaches to violence;
• Fund pilots to reduce violence in communities – including bullying, teen dating violence, and domestic violence – and to break the vicious cycle of violence and trauma;
• Integrate tactics learned from countering violent extremism abroad with public health approaches to violence to best address the rise in violence in America;
• Allow for the CDC, NIH, and other scientific agencies to study the full causes and effects of all forms of violence against Americans;
• Invest in early childhood interventions such as home visiting, lead abatement, and mental health and trauma services in order to break the cycle of violence.

Reducing costs in healthcare

We are all concerned about getting our money’s worth from spending on healthcare delivery including rising insurance premiums and prescription drug prices. The best way to reign in these costs is to invest in areas demonstrated to have positive returns on health outcomes such as housing, education, and the network of family and community relationships that keep Americans healthy.

The Republican Party Platform proposes reducing costs by converting Medicaid into block grants. This concerns us, as it risks depriving our most vulnerable residents of access to healthcare and adversely affecting health outcomes.

The block grant proposal is grounded in an appeal to flexibility. We support innovation that also protects the ability of states to maintain current levels of coverage with existing financing mechanisms and levels. Instead of spending 97 percent of our resources on direct care – often treating the symptoms without addressing the root causes – we should put some of that money where it will get the highest return. This could include funding for “alternatives to hospitalization for chronic diseases” and “disease prevention activities,” as the Platform recommends, but it should not stop there. We should, as a general policy, allow Medicaid dollars to fund innovative local programs that address the root causes of poor health. It is time for our nation to invest in healthcare instead of sick care, and to take the steps to truly foster well-being among individuals, families, and communities. If we want to reduce our healthcare expenditure, this is how we can do it.

We propose that the new Administration:

• Allow state Medicaid program to pay for cost-saving local programs that improve long-term health outcomes, like affordable housing; early childhood education and after-school programming; in-school eyeglasses provision; clean, lead-free water; and school nutrition programs and the elimination of food deserts;
• Empower CMS to expand testing of the Accountable Health Communities model, which fosters community well-being and reduces the need for direct care by helping to meet beneficiaries’ urgent social needs. CMS monies should, specifically, be allowed to fund not just the linking of beneficiaries with community services but those community services themselves;
• Continue to support effective entities that engage in evidence-based, cost-saving work like the Center for Medicare & Medicaid Innovation and the Patient-Centered Outcomes Research Institute.

Conclusion

This collection of proposals is far from exhaustive. But they represent important first steps in effecting a national change in our understanding of how we ought to invest in Americans’ health. That investment could not be more important. Protecting the health of our citizens is not about health alone. It is about the well-being and integrity of our families and neighborhoods. It is about our national security. It is about the kind of future we want for our country, and about whether we are willing to work for it.

On behalf of more than thirty million citizens in ten cities, I thank you for your consideration and for your commitment to improve the health and secure the future of Americans across our great country.

Sincerely,