The annual meeting of the American Public Health Association attracts a boisterous crowd of public health workers, scholars, advocates, students, and agitators of all stripes—particularly when it meets in Boston. The tradition of economic analysis at APHA is far from obvious, but it is a long and distinguished one. Those who surfed through the voluminous 141st annual APHA meeting program this past week in Boston were richly rewarded: a congeries of empirical studies of public health programs and policies with a solid economic bent. This collection included some of the field’s top health economists, presenting their observations shoulder-to-shoulder with those who design and implement public health strategies on a day-to-day basis.
For example, Harvard’s noted economist Richard Frank offered an intriguing analysis of the emergence and growth of “peer-led” programs designed as low-cost, community-based strategies for addressing mental health and substance abuse needs within states and communities. His analysis of the economics of adaptation in peer-led programs observed that the Affordable Care Act creates opportunities for states to expand the delivery of these non-traditional and “non-professional” services and supports, but the spread and sustainability of these programs will hinge on their ability to measure performance and document outcomes achieved by the public dollars invested. Clearly this is a message that applies to many of the strategies currently used in public health practice. As the newly appointed Assistant Secretary for Planning and Evaluation in the U.S. Department of Health and Human Services, Dr. Frank’s policy observations carry serious weight in my book.
Another widely recognized economist, Frank Chaloupka from UIC, gave an insightful analysis of evolution in the global market for tobacco products, noting that the trend toward privatization in these markets has allowed stronger tobacco control polices to emerge in many cases, but the countervailing force of consolidation in the global tobacco industry has strengthened manufacturers’ abilities to weaken and circumvent these policies. Chaloupka used APHA to announce the upcoming launch of a new website devoted to his work on the economics of tobacco control, www.tobacconomics.org
Of course, Chaloupka is also known for his pioneering work on the economics of obesity prevention, and new findings from his obesity research group were also on display at APHA. Of particular note, a study led by colleague Sandy Slater at UIC has produced some of the nation’s first empirical evidence about the effectiveness of joint use agreements (JUAs), which allow for public use of school facilities after school hours to expand opportunities for physical activity. The results from nationally representative survey data show that certain types of JUAs are associated with increased physical activity and decreased sedentary behavior among adolescents. As someone who regularly jumps the fence to run on my own public university’s track (a small act of civil disobedience), I resonate with these findings.
For the 9th year in a row, Peggy Honoré of the U.S. Department of Health and Human Services hosted APHA’s Public Health Finance Roundtable, which brings together some of the brightest minds to contemplate the perpetual problems of financing public health activities. Dr. Honoré and her colleagues at NACCHO provided an update on PHUNDS, a web-based tool for capturing, analyzing, and comparing indicators of financial performance for local public health agencies across the U.S. This tool has already proven useful in informing policy and administrative decision-making on local public health issues, such as weighing the financial benefits and costs associated with mergers between neighboring local public health jurisdictions. My colleagues at UK and I gave an update on the public health delivery and cost studies underway through our Public Health PBRN Program (the DACS studies mentioned in a recent post), as well as some new results from our ongoing work examining the effects of the recession on public health financing and delivery (slides here). Our work shows that changes in housing prices have had the largest and most persistent adverse effects on the delivery of public health services across the U.S., a reflection of the public health system’s heavy reliance on local property taxes as a financing instrument. As a consequence, the average community has 5% fewer public health protections in place today than they did prior to the recession, but the communities hit hardest by the recession have nearly 35% fewer protections. And our colleague Patrick Bernet from Florida Atlantic University rounded out the Roundtable with his work revealing that certain staffing patterns within local health departments made them more resilient to the effects of the recession –especially the combination of having fewer but more highly compensated full-time staff, along with the increased use of part-time staff positions.
The applied economic studies supported by our PHSSR Center permeated the APHA meeting this year. The University of Michigan’s Simone Singh, a recipient of one of our PHSSR Junior Investigator Awards, shared findings from her analysis of operational efficiency in the delivery of clinical preventive services among Florida’s local health departments, wherein she found evidence of sizable economies of scale but not economies of scope in delivery. The University of Colorado’s Adam Atherly presented work from the Colorado Public Health PBRN ‘s ongoing study of the impact of Colorado’s state law defining a minimum package of core public health services to be delivered by local agencies across the state. The early results show wide variation across communities in the resources devoted to these core services. UK doctoral student Rachel Hogg presented work from our National Longitudinal Survey of Public Health Systems examining changes in hospital contributions to public health activities, finding that hospitals have become increasingly important components of the public health enterprise over time (she won the Health Administration Section’s student research award for this work). The University of Arkansas’ Michael Morris together with Ohio’s Mathew Stephanak presented research examining the economic effects of consolidations among local public health agencies in Ohio, finding a trend toward reduced agency expenditures after consolidations involving small agencies.
One of my own new studies released at APHA this year used some recent methodological advances – in an active branch of econometrics known as local instrumental variables estimation – to generate community-specific estimates of how investments in public health activities influence preventable mortality and medical care utilization (slides here). We find that public health spending in low-income U.S. communities produces health and economic gains that are 20-45% larger than the effects observed for higher-income communities—suggesting that enhanced targeting of public health resources could generate substantial improvements in population health, even without new resources. The findings here have some clear implications for public health policy, but the methods we use for estimating heterogeneous treatment effects also have far-reaching applications in PHSSR and public health economics. We have another great economist to thank, the University of Washington’s Anirban Basu, for bringing these methods to health researchers and to the expanding area of comparative effectiveness research.
As usual, the APHA meeting offers way too much ferment to process in one sitting. I will revisit some of these intriguing economic studies and track their progress in future posts.