PREVENTIVE 

HEALTH ACTIVITIES

Available Information 

on Federal Spending, 

Cost Savings, and 

International 

Comparisons Has 

Limitations

Report to Congressional Requesters

December 2012

GAO-13-49

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United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-13-49, a report to 

congressional requesters

December 2012

PREVENTIVE HEALTH ACTIVITIES

Available Information on Federal Spending, Cost 

Savings, and International Comparisons Has 

Limitations 

Why GAO Did This Study

Preventive health activities have 

received attention for their potential to 

improve health outcomes or lower 

health care expenditures. While there 

is no widespread agreement on what 

constitutes preventive health activities, 

in this report they include clinical 

preventive services, such as 

immunizations provided in clinical 

settings, and community-oriented 

preventive health activities, such as 

health education media campaigns. A 

preventive health activity is considered 

cost saving if the activity costs less 

than the costs averted by it; an activity 

is cost-effective if it achieves benefits 

in a less costly way than alternatives. 

HHS, VA, and DOD administer 

programs that include preventive 

health activities.

GAO was asked to report on 

preventive health activities. This report 

provides available information and 

discusses the limitations of this 

information regarding (1) preventive 

health activities in programs 

administered by HHS, VA, and DOD 

and the departments’ spending on 

such activities; (2) reported cost 

savings from and cost effectiveness of 

preventive health activities; and 

(3) U.S. spending on preventive health 

activities compared to that of other 

countries.

GAO reviewed documents from HHS, 

VA, and DOD; interviewed officials

from those departments and 

researchers; conducted a literature 

review; and reviewed OECD data on 

national health spending.

HHS and VA provided technical 

comments on a draft of this report, 

which were incorporated as 

appropriate.

What GAO Found

The Departments of Health and Human Services (HHS), Veterans Affairs (VA), 

and Defense (DOD) administer programs that include preventive health activities 

such as health screenings and education campaigns, but the departments 

reported that they do not track department-wide spending on these activities. 

Departments reported that determining such spending is challenging because 

these activities can be integrated with other health activities. For fiscal year 2011, 

the departments provided to GAO a mix of information related to spending for 

preventive health activities, and noted limitations. These limitations included 

incomplete estimates, estimates that included activities that were preventionrelated but not specifically for clinical preventive services or community-oriented 

preventive health activities, and estimates that represented funding—not 

spending—information. Funding estimates represent amounts available to the 

departments at a particular time, but not necessarily actual spending. For fiscal 

year 2011, HHS combined estimates of spending for prevention for one agency 

with estimates of funding for nine other HHS agencies for a total of about 

$24 billion; however, the estimate did not include the Centers for Medicare & 

Medicaid Services, which oversees health coverage programs for over 

100 million individuals. VA and DOD estimated that, for example, fiscal year 2011 

spending for clinical preventive services was about $576 million and $1 billion, 

respectively.

Researchers, reports, and articles have indicated that some preventive health 

activities may result in cost savings—that is, the costs averted, such as medical 

costs to treat a disease or condition, exceed the cost of implementing it—and a 

number of preventive health activities, while not necessarily cost saving, may be 

cost-effective—that is, the activity provides good value at low cost relative to 

alternative activities. For example, according to one report that synthesized the 

results of three reviews, two clinical preventive services—counseling on the use 

of low-dose aspirin to reduce coronary heart disease and childhood 

immunizations—were considered to be cost saving. Researchers noted, 

however, that estimates of cost savings or cost-effectiveness are affected by 

multiple factors, such as how an activity is targeted. In addition, Centers for 

Disease Control and Prevention officials and others reported that a lack of key 

data may affect estimates of cost savings or cost-effectiveness and reported 

taking steps toward improving available information.

Data for international comparisons of countries’ spending specifically for 

preventive health activities are not available. Instead, data available from the 

Organization for Economic Co-operation and Development (OECD) combine 

spending on certain preventive health activities—including community-oriented 

preventive health activities, such as vaccination programs—with spending on 

other public health activities, such as disease surveillance. On the basis of these 

data, the United States ranked 8th among 23 OECD member countries in the 

percentage of total health care spending reported for prevention and public 

health services. However, these data have limitations. For example, they do not 

include U.S. spending for preventive services provided in physicians’ offices or 

hospitals in the public and private sectors. View GAO-13-49. For more information, 

contact Katherine Iritani at (202) 512-7114 or 

iritanik@gao.gov.
Page i GAO-13-49 Preventive Health Activities

Letter 1 

Background 7

HHS, VA, and DOD Programs Include Preventive Health Activities, 

but Department-wide Spending on These Activities Is Not 

Specifically Tracked 14

Some Preventive Health Activities May Be Cost Saving or CostEffective, but Multiple Factors Affect Estimates, and Key Data 

May Be Lacking 21

International Data on Preventive Health Activities Are Not 

Available, but United States Ranks Eighth in OECD Category 

That Combines Spending on Prevention and Public Health 

Services 28

Concluding Observations 32

Agency Comments 33

Appendix I Requirements Related to Preventive Health Activities in 

the Duncan Hunter National Defense Authorization Act 34

Appendix II Department of Health and Human Services Estimates 

of Spending and Funding for Preventive Health Activities 36

Appendix III Department of Veterans Affairs Estimates of Spending 

and Funding for Preventive Health Activities 40

Appendix IV Department of Defense Estimates of Spending for 

Preventive Health Activities 42

Appendix V GAO Contact and Staff Acknowledgments 44

Tables

Table 1: Selected HHS Agencies and Their Functions 8

Contents 
Page ii GAO-13-49 Preventive Health Activities

Table 2: Types of Preventive Health Activities Included in 

Programs Administered by HHS Agencies 15

Table 3: Effect of Targeting on Cost-Effectiveness Ratio for 

Selected Preventive Health Activities 25

Table 4: DOD Estimates of Spending for Providing Clinical 

Preventive Services in DOD’s Direct Care and Purchased 

Care Systems, Fiscal Years 2010 and 2011 42

Figures

Figure 1: Total Health Care Spending per Capita, by OECD Member 

Country, 2010 13

Figure 2: Spending for Prevention and Public Health Services as a 

Percentage of Total Health Spending, by OECD Member 

Country, 2010 29

Figure 3: Spending for Prevention and Public Health Services as a 

Percentage of Gross Domestic Product, by OECD Member 

Country, 2010 30

Figure 4: Spending for Prevention and Public Health Services per 

Capita, by OECD Member Country, 2010 31
Page iii GAO-13-49 Preventive Health Activities

Abbreviations

ACF Administration for Children and Families

ACL Administration for Community Living

ACIP Advisory Committee on Immunization Practices

AHRQ Agency for Healthcare Research and Quality

AOA Administration on Aging

ASFR Office of the Assistant Secretary for Financial Resources

CDC Centers for Disease Control and Prevention

CMS Centers for Medicare & Medicaid Services

DOD Department of Defense

FDA Food and Drug Administration

HHS Department of Health and Human Services

HIV human immunodeficiency virus

HPV human papillomavirus

HRSA Health Resources and Services Administration

IHS Indian Health Service

LDL low-density lipoprotein

NIH National Institutes of Health

NHLBI National Heart, Lung, and Blood Institute

OASH Office of the Assistant Secretary for Health

OECD Organization for Economic Co-operation and Development

QALY quality-adjusted life-year

SAMHSA Substance Abuse and Mental Health Services 

 Administration

USPSTF U.S. Preventive Services Task Force

VA Department of Veterans Affairs

VHA Veterans Health Administration

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Page 1 GAO-13-49 Preventive Health Activities

United States Government Accountability Office

Washington, DC 20548

December 6, 2012

The Honorable Max Baucus

Chairman

Committee on Finance

United States Senate

The Honorable Tom Harkin

Chairman

Committee on Health, Education, Labor, and Pensions

United States Senate

The Honorable Carl Levin

Chairman

Committee on Armed Services

United States Senate

In recent years, preventive health activities have received attention for 

their potential to improve health outcomes or lower health care 

expenditures. Preventive health activities can prevent health conditions 

from occurring, or screen for or diagnose existing health conditions. For 

example, vaccinations can prevent infectious diseases, and 

mammograms are used to screen for breast cancer. Preventive health 

activities can also manage diagnosed health conditions and prevent 

certain conditions from worsening—for example, weight-reduction 

counseling to help manage diabetes. While there is no widespread 

agreement on what constitutes preventive health activities, in this report 

preventive health activities include clinical preventive services and 

community-oriented preventive health activities. Clinical preventive 

services are services that are provided to individuals in clinical settings 

such as immunizations, screenings, and counseling, and communityoriented preventive health activities are activities to improve the health of 

people in a community such as health education media campaigns and 

health screenings at community health fairs. 

The Department of Health and Human Services (HHS), the Department of 

Veterans Affairs (VA), and the Department of Defense (DOD) administer 

programs that provide preventive health activities and other health 

services to millions of Americans. For example, HHS’s Medicare and 

 
 

Page 2 GAO-13-49 Preventive Health Activities

Medicaid programs provide coverage for clinical preventive services for 

seniors and low-income adults and children,

1 VA provides clinical 

preventive services and community-oriented preventive health activities 

for veterans and other eligible beneficiaries, and DOD provides clinical 

preventive services and community-oriented preventive health activities 

for active duty personnel and other beneficiaries. According to the 

National Prevention Strategy prepared by the National Prevention 

Council—a council that includes the heads of these three departments—

the federal government will support preventive health activities to promote 

health and wellness by taking new or continuing actions such as 

promoting and expanding research efforts to identify high-priority 

preventive health activities.2

Preventive health activities may have impacts on health care costs and 

improve health outcomes. Preventive health activities are considered to 

be cost saving when the cost of implementing the activity is less than 

costs—such as future medical costs to treat a disease or condition—that 

could be averted by the preventive health activity. Preventive health 

activities that may improve health outcomes are considered cost-effective 

if the activity generates benefits, such as improved health outcomes, in a 

less costly way than alternatives—that is, they provide good value at 

relatively low cost.

State and local governments, nonprofit 

organizations, companies in the private sector, as well as governments in 

other countries, also administer programs that include preventive health 

activities.

You asked us to provide information on preventive health activities, 

including spending on these activities by HHS, VA, and DOD and 

limitations in this information. This report provides available information 

 

1

Medicare is the federal health insurance program for people age 65 or older, individuals 

under age 65 with certain disabilities, and individuals diagnosed with end-stage renal 

disease. Medicaid is a joint federal and state program that finances health care coverage 

for certain low-income individuals and families.

2

See National Prevention Council, National Prevention Strategy (Washington, D.C.: U.S. 

Department of Health and Human Services, Office of the Surgeon General, 2011). The 

National Prevention, Health Promotion and Public Health Council (referred to as the 

National Prevention Council) was established under the Patient Protection and Affordable 

Care Act (Pub. L. No. 111-148, § 4001, 124 Stat. 119, 538 (2010)) and is composed of the 

heads of 17 federal agencies and chaired by the Surgeon General. Information about the 

National Prevention Council and its National Prevention Strategy is available at 

http://www.healthcare.gov/prevention/nphpphc (accessed Aug. 30, 2012).
 

Page 3 GAO-13-49 Preventive Health Activities

and discusses the limitations of this information regarding (1) preventive 

health activities included in programs administered by HHS, VA, and 

DOD and the departments’ spending information on such activities; 

(2) reported cost savings from and cost-effectiveness of preventive health 

activities; and (3) U.S. spending on preventive health activities compared 

to that of other countries.

To provide information and discuss the limitations of this information 

regarding preventive health activities included in programs administered 

by HHS, VA, and DOD and the departments’ spending information on 

such activities, we reviewed documents and interviewed officials from 

HHS, VA, and DOD. We asked officials from each of these departments 

to describe completed or ongoing efforts, if any, to identify and track 

spending on clinical preventive services and community-oriented 

preventive heath activities included in programs administered by their 

respective departments, and we reviewed the related documents they 

provided.3

• For HHS, we reviewed documents provided by HHS’s Office of the 

Assistant Secretary for Financial Resources (ASFR) (the office that 

provides guidance to HHS’s Office of the Secretary on all aspects of 

HHS’s budget) that include estimates of spending and other 

information, reviewed documents from HHS agencies that identified

We asked the departments to provide readily available 

information from their data systems or existing documents. As a result, 

the information provided by the departments may not be based on a 

uniform definition of preventive health activities or comparable estimates 

of spending. We did not independently verify the information provided by 

the departments nor did we assess the rationale for including or excluding 

particular preventive health activities in the information that the 

departments provided.

 

3

We did not contact the Department of the Treasury to review federal tax expenditures, 

which are not within the scope of our work. Tax expenditures are preferential provisions in 

the tax code, such as exemptions and exclusions from taxation, deductions, credits, 

deferral of tax liability, and preferential tax rates that result in forgone revenue for the 

federal government. The revenue that the government forgoes is viewed by many analysts 

as spending channeled through the tax system. According to the Office of Management 

and Budget, in fiscal year 2011, for example, the tax exclusion for employer-provided 

health care alone totaled about $267.8 billion in forgone federal revenue. See Office of 

Management and Budget, Analytical Perspectives, Budget of the United States 

Government, Fiscal Year 2013 (Washington, D.C.: 2012).
 

Page 4 GAO-13-49 Preventive Health Activities

preventive health activities included in programs administered by the 

agencies, and interviewed ASFR and HHS agency officials.4

• For VA, we reviewed documents describing estimates of spending 

developed by VA’s Veterans Health Administration (VHA), which 

administers VA’s health care system, and we interviewed VHA 

officials. Specifically, we reviewed documents identifying selected 

clinical preventive services provided in VA medical facilities and 

describing spending estimates developed by VHA’s Allocation 

Resource Center for these services.5 In addition to estimates of 

spending for clinical preventive services, we reviewed VA documents 

identifying community-oriented preventive health activities included in 

programs administered by VA’s National Center for Health Promotion 

and Disease Prevention and VA’s Clinical Public Health Group. We 

also interviewed officials who provided these documents.

• For DOD, we reviewed documents describing estimates of spending 

developed by the department and interviewed DOD officials about the 

department’s preventive health activities. For example, to learn about 

DOD’s clinical preventive services provided through TRICARE—

DOD’s program that provides health care to active duty personnel and 

other beneficiaries, including retired servicemembers—we reviewed 

documents describing spending estimates provided by DOD’s 

TRICARE Management Activity (the DOD component that oversees 

TRICARE) and interviewed officials from the TRICARE Management 

Activity.6

For all the departments, we reviewed documents describing limitations of 

the information or discussed limitations with HHS, VA, and DOD officials. 

We did not independently verify the accuracy of the information. We 

determined the information to be sufficiently reliable for providing 

information on preventive health activities in programs administered by 

 

4

In this report we use the term agency to refer to HHS agencies, as well as the Office of 

the Assistant Secretary for Health.

5

VHA’s Allocation Resource Center is responsible for developing, implementing, and 

maintaining management information systems that provide data for VHA’s budget 

process.

6

We also reviewed documents, including DOD reports to Congress, related to preventive 

health provisions in the Duncan Hunter National Defense Authorization Act for Fiscal Year 

2009. Pub. L. No. 110-417, §§ 711- 714, 122 Stat. 4536, 4500-04 (2008).
 

Page 5 GAO-13-49 Preventive Health Activities

HHS, VA, and DOD and on the departments’ estimates of spending on 

such activities, and limitations of this information. Where we identified 

limitations, we report them.

To provide information about the reported cost savings from and costeffectiveness of preventive health activities, we conducted a literature 

review and interviewed researchers and government officials.7

To provide information on U.S. spending on preventive health activities 

compared to that of other countries, we reviewed data collected by the 

Organization for Economic Co-operation and Development (OECD) on 

For our 

literature review, we searched four databases—EMBASE, MEDLINE, 

SciSearch, and ProQuest—and identified 23 articles that met our 

inclusion criteria—that is, each of the 23 articles reviewed multiple 

research studies; clearly described a methodology; was published in a 

peer-reviewed journal between January 2007 and March 2012; and 

identified U.S. based services that were cost saving or cost-effective, or 

factors that affect whether a preventive health activity is cost saving or 

cost-effective. In addition to conducting a literature review of articles 

published in peer-reviewed publications, we reviewed government and 

independent reports, including reports published by nonprofit 

organizations that were referenced in articles in our literature review or 

were suggested to us by the federal officials and researchers we 

interviewed. We interviewed officials from the following HHS agencies 

that provide research support to organizations that work on issues related 

to preventive health activities: the Agency for Healthcare Research and 

Quality (AHRQ)—specifically, we spoke to officials who provide research 

support to the U.S. Preventive Services Task Force (USPSTF); and the 

Centers for Disease Control and Prevention (CDC)—specifically, we 

spoke to officials in the National Center for Chronic Disease Prevention 

and Health Promotion and the National Center for Immunization and 

Respiratory Diseases who provide support to the Community Preventive 

Services Task Force and the Advisory Committee on Immunization 

Practices (ACIP), respectively. We also interviewed members of ACIP, 

including the ACIP Chair. 

 

7

We interviewed researchers at two nonprofit organizations that focus on preventive 

health activities and two academic institutions. These researchers were referred to us by 

federal officials or published articles in peer-reviewed publications or reports on the topic 

of the cost savings or cost-effectiveness of preventive health activities, including articles or 

reports cited by HHS.
 

Page 6 GAO-13-49 Preventive Health Activities

national health spending for the United States and other OECD member 

countries.8 OECD is an organization that, among other things, collects 

data on health spending from member countries. We reported relevant 

2010 spending statistics for OECD member countries using data available 

on OECD’s website.9

We conducted our work from December 2011 through December 2012 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform our work to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our research objectives. We believe 

We also identified trends for the United States over 

time by comparing rankings for 2010 spending statistics with similar 

rankings for 2001 through 2009. We reviewed documents published by 

OECD and interviewed experts—including officials from the Centers for 

Medicare & Medicaid Services’ (CMS) Office of the Actuary (the office 

that submits the U.S. health care spending data to OECD) as well as 

researchers—to learn about guidelines established by OECD and the 

data submitted by OECD member countries. While there are limitations to 

using OECD data, the researchers we interviewed reported that the 

OECD data are the best available data for making international 

comparisons on health spending. We did not independently verify the 

accuracy of the data. We assessed the reliability of the data and 

determined that the data were sufficiently reliable for purposes of 

presenting available data comparing U.S. spending with that of other 

countries, noting limitations associated with these data.

 

8

As of August 2012, OECD had 34 member countries. According to OECD, its member 

countries include many of the world’s most advanced economies but also emerging 

economies like Mexico, Chile, and Turkey. OECD lists the member countries on its 

website: 

http://www.oecd.org/document/58/0,3746,en_2649_201185_1889402_1_1_1_1,00.html

(accessed Aug. 8, 2012). OECD also reports data on health outcomes. OECD health data 

are used by researchers and others to compare health spending and outcomes in the 

United States with that of other countries. 

9

We used 2010 spending data because it was the most recent data available for most 

member countries at the time of our review. As of July 2012, OECD had posted 2010 

health spending data from 28 of its 34 member countries, and posted data on prevention 

and public health services from 23 of these countries. Data from these 23 countries were 

used for this report. To identify the rankings for relevant 2010 spending statistics, we used 

the OECD.Stat database available on OECD’s website 

(http://www.oecd.org/document/30/0,3746,en_2649_37407_12968734_1_1_1_37407,00.h

tml, accessed July 11, 2012).
 

Page 7 GAO-13-49 Preventive Health Activities

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our research objectives.

HHS is the federal government’s principal department for protecting the 

health of all Americans and providing essential human services, 

especially for vulnerable populations. For fiscal year 2011, HHS’s 

department-wide expenditures totaled about $891 billion. HHS agencies 

that administer programs that include preventive health activities have 

missions and key functions that vary. For example, CMS administers the 

Medicare and Medicaid programs and the Children’s Health Insurance 

Program, which provide health care insurance for more than 100 million 

adults and children. Three other agencies—the Indian Health Service 

(IHS), the Health Resources and Services Administration (HRSA), and 

the Substance Abuse and Mental Health Services Administration 

(SAMHSA)—provide health care services or support systems that provide 

these services. Two agencies—the National Institutes of Health (NIH) and 

AHRQ—are primarily research agencies. CDC develops and supports 

public health prevention programs and systems, such as disease 

surveillance and provider education programs. (See table 1 for more 

information about these HHS agencies.)

Background 

HHS, VA, and DOD Health 

Care
 

Page 8 GAO-13-49 Preventive Health Activities

Table 1: Selected HHS Agencies and Their Functions

HHS agency Agency functions 

Administration for Children and Families 

(ACF) 

Administers programs to promote the economic and social well-being of children, youth, 

families, and communities, focusing particular attention on vulnerable populations, such 

as children in low-income families, refugees, Native Americans, and children in foster 

care. 

Agency for Healthcare Research and Quality 

(AHRQ)

Supports research that examines how people get access to health care, how much 

health care costs, and what happens to patients as a result of the health care they 

receive.

Administration for Community Living (ACL) Administers programs to advance the concerns and interests of older Americans, 

people with disabilities, and their families through national networks of service, system 

change efforts, and protections to promote optimal life outcomes.

a

Centers for Disease Control and Prevention 

(CDC)

Administers programs to prevent significant health conditions and their risk factors, 

including infectious diseases, chronic diseases, birth defects and developmental 

disabilities, intentional and unintentional injury, and health conditions from 

environmental exposures.

Centers for Medicare & Medicaid Services 

(CMS) 

Oversees the financing of health care services for the 43 million beneficiaries covered 

through Medicare and the nearly 60 million low-income individuals (including adults and 

children) covered through Medicaid and the Children’s Health Insurance Program.

Health Resources and Services 

Administration (HRSA)

Administers programs to improve access to health care services for people who are 

uninsured, isolated, or medically vulnerable.

Indian Health Service (IHS) Provides health care to approximately 2.2 million American Indians and Alaska Natives 

through a network of 650 hospitals, clinics, and health stations.

National Institutes of Health (NIH) Supports medical research in the United States. It conducts and funds research about, 

for example, the causes, diagnosis, prevention, and cure of human diseases.

Office of the Assistant Secretary for Health 

(OASH) 

Coordinates population-based public health and science activities across HHS 

agencies.

Substance Abuse and Mental Health 

Services Administration (SAMHSA)

Administers programs to promote emotional health and reduce the likelihood of mental 

illness, substance abuse, and suicide.

Source: GAO summary of HHS information.

a

VA also provides health care services that include preventive health 

activities. VA operates one of the largest health care delivery systems in 

the nation. VA provides a range of health care services to eligible 

veterans and certain eligible dependents or survivors of veterans. These 

services include primary care, inpatient and outpatient surgery, 

prosthetics, mental health services, prescription drugs, nursing home 

care, and preventive health activities. To provide this care, VA operates 

about 150 hospitals, 130 nursing homes, and 800 outpatient clinics, as 

well as other facilities. In fiscal year 2011, VA spent about $51 billion on 

health care services and provided health care services to about 

6.2 million patients.

In April 2012, HHS created the ACL by combining the Administration on Aging (AOA), the Office on 

Disability, and the Administration on Intellectual and Developmental Disabilities.
 

Page 9 GAO-13-49 Preventive Health Activities

DOD operates a large, complex health system that in fiscal year 2011 

provided health insurance coverage for about 9.6 million active duty 

personnel and other beneficiaries, including eligible family members and 

retired servicemembers. DOD’s health system consists of the Office of 

the Assistant Secretary for Health Affairs, the medical departments of the 

Army, Navy, and Air Force; the Joint Chiefs of Staff; the Combatant 

Command surgeons; and the TRICARE network of health care providers. 

DOD delivers health care services—including diagnostic, therapeutic, 

inpatient, and outpatient care—through the military services’ medical 

departments at 59 military treatment facilities, 365 ambulatory care 

clinics, and 281 dental clinics, which make up what is known as the direct 

care system. DOD also delivers similar services to TRICARE 

beneficiaries through its purchased care system, which consists of 

network and nonnetwork private-sector civilian primary and specialty care 

providers, hospitals, pharmacies, and suppliers. In fiscal year 2011, 

spending in DOD’s health system totaled about $52 billion.

Preventive health activities may result in cost savings and may be costeffective. An activity may be cost saving if the costs averted by the 

activity, such as future medical costs to treat a disease or condition, 

exceed the cost of implementing the preventive health activity. An activity 

may be considered cost-effective if it generates benefits, such as 

improved health outcomes, in a less costly way than alternatives. Costeffectiveness analysis can help to evaluate whether the improvement in 

health care outcomes justifies the expenditures relative to other choices.

Cost-effectiveness analyses typically compare the costs and health 

outcomes between two activities or compare an activity with no 

intervention. Estimates of cost-effectiveness are typically presented as a 

ratio of the net costs to the net outcomes of utilizing one preventive health 

activity over another. In presenting outcomes of cost-effectiveness 

analyses, researchers often use a measure called the quality-adjusted 

life-year (QALY), which takes into account both the number and quality of 

years added by an intervention. A year in perfect health is worth 1 QALY, 

and a year with less than perfect health—for example, with an adverse 

health condition—is generally worth between 0 and 1 QALY. The 

preventive health activity with the lower cost-effectiveness ratio is 

preferred because it costs less to achieve the desired health outcome. 

While there is no agreement on the specific threshold for determining that 

Estimating Cost Savings 

and Cost-Effectiveness of 

Preventive Health 

Activities
 

Page 10 GAO-13-49 Preventive Health Activities

an activity is cost-effective, researchers have used a threshold of $50,000 

per QALY or $100,000 per QALY to consider a preventive health activity 

to be cost-effective.10

In the United States, three federally supported organizations—USPSTF, 

ACIP, and the Community Preventive Services Task Force—assess 

information about preventive health activities and make recommendations 

to providers and policymakers based on an activity’s effectiveness—that 

is, how well the activity produces a desired health outcome.

• USPSTF is an independent panel of nonfederal experts in prevention 

and evidence-based medicine that makes recommendations to 

primary care clinicians on clinical preventive services.11 USPSTF 

reviews evidence from randomized control trials and other studies 

documenting the effectiveness of clinical preventive services.12 It then 

issues recommendations for providers and may include guidance on 

the sex and age groups most likely to benefit from the service, as well 

as the interval of the service. The USPSTF is convened by AHRQ, 

and AHRQ also provides it with administrative, research, technical, 

and dissemination support.

• ACIP—a federal advisory committee of 15 experts selected by the 

Secretary of Health and Human Services—makes recommendations 

for vaccination administration, including a schedule of recommended 

vaccines for adults and children.13

 

10Because there is no commonly accepted cost-effectiveness ratio threshold that 

determines whether a preventive health activity is cost-effective, the thresholds 

researchers apply may vary. Given such variations, a preventive health activity may be 

found to be cost-effective in one research study that uses a particular threshold, but not in 

another study that applies a different threshold. For example, a preventive health activity 

may be considered cost-effective when using a threshold cost-effectiveness ratio of 

$100,000 per QALY, but when a lower cost-effectiveness threshold is used, such as 

$50,000 per QALY, the same activity might not be considered cost-effective.

As part of its recommendation 

process, ACIP reviews information on the cost or economic impact of 

11USPTSF is made up of 16 volunteer members who are primary care providers (such as 

internists, pediatricians, family physicians, obstetricians/gynecologists, nurses, and 

behavioral health specialists).

12The USPSTF does not consider economic information, such as whether a preventive 

health service is cost saving or cost-effective, as part of its recommendation process.

13ACIP recommendations are not considered official until they are approved by the CDC 

Director and published in CDC’s Morbidity and Mortality Weekly Report. 
 

Page 11 GAO-13-49 Preventive Health Activities

the vaccinations it evaluates. CDC provides ACIP with management 

and support services.

• The Community Preventive Services Task Force—an independent, 

nonfederal panel of 15 members appointed by the CDC Director—

conducts systematic reviews of community-oriented preventive 

services, programs, and policies and issues recommendations and 

findings to help inform decision making about policy, practice, and 

research. The task force examines the evidence, produces findings 

and recommendations about effective and ineffective programs, 

services, and policies, and identifies research gaps that need to be 

filled. While the Community Preventive Services Task Force does not 

consider economic information, such as whether a preventive health 

service is cost saving or cost-effective, as part of its recommendation 

process, it makes publicly available the economic information for the 

preventive health activities it recommends.14 The task force reviews 

research, including cost-effectiveness research, funded and 

conducted by CDC’s Epidemiology and Analysis Program Office. CDC 

staff support the Community Preventive Services Task Force by 

conducting the systematic reviews with oversight from the task force, 

and by disseminating task force recommendations and findings.

OECD is an international economic organization in which its member 

countries discuss, develop, and analyze economic and social policy. 

OECD collects data on total health spending and spending on specific 

health categories such as medical goods, inpatient care, and outpatient 

care, from its member countries, including the United States. For the 

United States, CMS’s Office of the Actuary reports national health 

spending data to OECD. To make the data collected from member 

countries as comparable as possible, OECD establishes guidelines for 

the types of spending that should be included in various spending 

 

14The Community Preventive Services Task Force reviews published information related 

to the cost savings or cost-effectiveness of the preventive health activities it recommends 

and posts this information online. For example, the task force finding and rationale 

statement on interventions for children and adolescents with asthma included information 

from studies that considered costs and benefits of the interventions—see 

http://www.thecommunityguide.org/asthma/rrchildren.html (accessed Aug. 17, 2012). 

OECD 
 

Page 12 GAO-13-49 Preventive Health Activities

categories.15

 

15OECD disseminates its guidelines in a published manual called A System of Health 

Accounts. The manual containing guidelines for OECD’s 2010 data—the data used for this 

report—was released by OECD in 2000. A revised version of the manual was released in 

November 2011.

For example, OECD’s guidelines for total health spending in 

2010 included spending in both the public and private sectors on health 

services conducted in hospitals and other facilities or settings such as 

long-term nursing care centers and physicians’ offices. The guidelines 

also included total spending on pharmaceuticals, health administration, 

and public health. In 2010, the United States ranked first among OECD 

countries in total health care spending (about $2.5 trillion). The United 

States also ranked first among OECD countries in total health care 

spending as a percentage of the country’s gross domestic product (about 

18 percent) and in total health care spending per capita─$8,233 per 

person (see fig. 1).
 

Page 13 GAO-13-49 Preventive Health Activities

Figure 1: Total Health Care Spending per Capita, by OECD Member Country, 2010

Note: This figure presents a summary of 2010 data on total health care spending per capita for 28 

OECD member countries. OECD adjusted spending per capita for purchasing power parity.
 

Page 14 GAO-13-49 Preventive Health Activities

HHS agencies identified preventive health activities—specifically, clinical 

preventive services and community-oriented preventive health activities—

included in programs that they administer, with different programs 

targeting different populations. (See table 2 for types of preventive health 

activities included in programs that HHS agencies administer and 

examples of such activities.) For example, CMS’s Medicare and Medicaid 

programs provide coverage for clinical preventive services for Medicare 

and Medicaid beneficiaries, while IHS’s programs provide preventive 

health activities for American Indians and Alaska Natives. CDC 

administers programs that include community-oriented preventive health 

activities such as the National Tobacco Control Program, which provides 

access to quit lines and ad campaigns to reduce smoking. 

HHS, VA, and DOD 

Programs Include 

Preventive Health 

Activities, but 

Department-wide 

Spending on These 

Activities Is Not 

Specifically Tracked

HHS, VA, and DOD 

Identified Preventive 

Health Activities Included 

in the Programs They 

Administer 
 

Page 15 GAO-13-49 Preventive Health Activities

Table 2: Types of Preventive Health Activities Included in Programs Administered by HHS Agencies

Type of preventive health activities included

HHS agency

Clinical preventive 

services

Community-oriented 

preventive health 

activities Example

Administration for 

Children and Families 

(ACF) 

x ACF awards discretionary grants to states through its 

Office of Refugee Resettlement Preventive Health 

Services program to coordinate and promote access 

to clinical preventive services that include health 

screenings for refugees.

Agency for 

Healthcare Research 

and Quality (AHRQ)

x AHRQ convenes the U.S. Preventive Services Task 

Force (USPSTF)—a panel of experts that makes 

recommendations on clinical preventive services—

and provides administrative, research, technical, and 

dissemination support for the USPSTF.

Administration for 

Community Living 

(ACL)a

x ACL administers programs that promote opportunity, 

healthy lifestyles, and healthy behaviors for older 

Americans, people with disabilities, and their families 

through education, research and service across 

diverse networks of state and local programs.

Centers for Disease 

Control and 

Prevention (CDC)

x x CDC administers programs that include communityoriented preventive health activities such as the 

National Tobacco Control Program, which provides 

access to quit lines and ad campaigns to reduce 

smoking. CDC also supports the Community 

Preventive Services Task Force, which conducts 

reviews on the effectiveness of community-oriented 

preventive health activities. CDC’s Vaccines for 

Children program and Section 317 Immunization 

Program fund the purchasing and delivery of vaccines 

to vulnerable populations.

Centers for Medicare 

& Medicaid Services 

(CMS) 

x x CMS’s Medicare and Medicaid programs provide 

coverage for many clinical preventive services such 

as wellness examinations, screenings, vaccinations, 

and counseling for Medicare and Medicaid 

beneficiaries. CMS’s Everyone with Diabetes Counts 

program includes community-oriented preventive 

health activities that seek to educate Medicare 

beneficiaries with diabetes in vulnerable populations 

and increase their health literacy.

Health Resources 

and Services 

Administration 

(HRSA) 

x x HRSA’s National Health Service Corps supports the 

provision of clinical preventive health activities and 

community-oriented preventive health activities by 

offering assistance to underserved communities in 

every state to recruit and retain primary care 

providers.
 

Page 16 GAO-13-49 Preventive Health Activities

Type of preventive health activities included

HHS agency

Clinical preventive 

services

Community-oriented 

preventive health 

activities Example

Indian Health Service 

(IHS)

x x IHS provides clinical preventive services to American 

Indians and Alaska Natives through its network of 

hospitals and clinics. IHS’s Community Health 

Representative program supports communityoriented preventive health activities by, for example, 

providing health education in patients’ homes and 

schools and facilitating screening at health fairs.

National Institutes of 

Health (NIH)

x x NIH supports research designed to yield results 

directly applicable to identifying and assessing risk, 

and to develop interventions for preventing or 

ameliorating high-risk behaviors, the occurrence of 

disease, disorder, injury, or progression of detectable 

but asymptomatic disease. Research projects support 

clinical preventive services and community-oriented 

preventive health activities.

Office of the Assistant 

Secretary for Health 

(OASH) 

x x OASH leads the President’s Council on Physical 

Fitness, Sports, and Nutrition in efforts to increase 

physical activity in the United States. The council 

advises the President through the Secretary of Health 

and Human Services about physical activity, fitness, 

sports, and good nutrition. In addition, OASH 

provides funding support for Title X family planning 

clinics which provide clinical preventive services to 

millions of individuals.

Substance Abuse and 

Mental Health 

Services 

Administration 

(SAMHSA) 

x x SAMHSA’s Safe Schools/Healthy Students Initiative 

includes both clinical preventive services and 

community-oriented preventive health activities. It 

provides funding to local law enforcement, juvenile 

justice agencies, social services, mental health 

agencies, and other community organizations to plan 

and implement comprehensive and coordinated 

programs, policies, and service delivery systems that 

promote mental, emotional, and behavioral well-being 

and prevent violence and drug abuse among children 

and youth.

Source: GAO summary of HHS information.

a

VA also identified clinical preventive services and community-oriented 

preventive health activities in the programs it administers for veterans and 

other beneficiaries in VA facilities. Examples of the clinical preventive 

services that VA provides to beneficiaries who are eligible for such 

services include immunizations; dental cleanings; depression screenings; 

post-traumatic stress screenings; diabetes screenings; hypertension 

screenings; tobacco use screenings and counseling; and screenings for 

In April 2012, HHS created the ACL by combining the Administration on Aging (AOA), the Office on 

Disability, and the Administration on Intellectual and Developmental Disabilities.
 

Page 17 GAO-13-49 Preventive Health Activities

breast cancer, cervical cancer, and colorectal cancer. VA provides these 

services to beneficiaries in VA medical centers, community-based 

outpatient clinics, and other VA facilities.16

In addition, DOD identified clinical preventive services and communityoriented preventive health activities included in programs administered 

through the department’s direct care and purchased care systems for 

active duty personnel and other beneficiaries, including retired 

servicemembers. Examples of services include immunizations; 

depression screenings; dental screenings; diabetes screenings; obesity 

screenings; vision screenings; and screenings for breast cancer, cervical 

cancer, and colorectal cancer. DOD’s direct care system also includes 

community-oriented preventive health activities such as tobacco 

cessation and obesity and alcohol abuse prevention programs. For 

example, DOD’s TRICARE Management Activity coordinates the Quit 

Tobacco—Make Everyone Proud program, which is a tobacco cessation 

marketing and education campaign to increase awareness of the negative 

effects of tobacco use and decrease its use and acceptance in the 

military work environment. DOD also reported that the Duncan Hunter 

National Defense Authorization Act for Fiscal Year 2009 required DOD to 

reduce beneficiary cost sharing and undertake certain preventive health 

activities.

In addition, VA’s National 

Center for Health Promotion and Disease Prevention provides support for 

clinical staff in VA medical facilities and coordinates VA’s communityoriented preventive health activities. For example, the center leads the 

department’s efforts to provide guidance to clinicians and veterans on a 

range of clinical preventive services, and administers the department’s 

MOVE! Weight Management Program. VA’s Clinical Public Health 

Group—an office that addresses public health concerns through, among 

other things, education and outreach, policy development, and 

research—also administers community-oriented preventive health 

activities, including prevention education for tobacco use, human 

immunodeficiency virus (HIV), and influenza.

17

 

16In addition to services it provides directly, VA also operates a fee-based purchased care 

program that covers health care services—including dental services, outpatient care, 

inpatient care, emergency care, and medical transportation—provided to eligible veterans 

outside of the VA when a VA facility is not available. Total annual fee payments under this 

program were about $3.8 billion in fiscal year 2009. VA did not identify clinical preventive 

services provided through its fee-based purchased care program.

(For more information on these provisions, see app. I.)

17Pub. L. No 110-417, §§711-714, 122 Stat. 4356, 4500-04 (2008).
 

Page 18 GAO-13-49 Preventive Health Activities

HHS, VA, and DOD reported that they do not specifically track 

department-wide spending18

HHS, VA, and DOD provided us with a mix of information related to 

spending for preventive health activities, and noted limitations associated 

with the information. For example, some spending for preventive health 

activities was not included, or prevention-related spending was included 

but was not for preventive health activities. In addition, in some cases, 

information provided by HHS and VA did not present estimated spending 

for these activities, but rather funding, which represents an amount 

available at a particular time, but does not necessarily reflect actual 

spending that occurred.

on preventive health activities and that 

determining total spending on preventive health activities is challenging 

because such activities are often integrated with other activities. 

According to HHS, VA, and DOD officials, spending for preventive health 

activities is not easily distinguished in their data from spending on other 

health activities. For example, VA and DOD officials reported that it can 

be challenging to identify the portion of spending linked to a clinical 

preventive service and identify the portion that is for treatment when both 

types of services are provided in a single patient visit. The departments 

noted that they are not required to specifically track department-wide 

spending on all the preventive health activities included in the programs 

they administer.

19

 

18Spending means obligations, including those for which expenditures have been made. 

The term obligation refers to a definite commitment by a federal agency that creates a 

legal liability to make payments immediately or in the future. Agencies incur obligations, 

for example, when they award grants or contracts to private entities. An expenditure is the 

actual spending of money by the issuance of checks, disbursement of cash, or electronic 

transfer of funds made to liquidate a federal obligation. See GAO, A Glossary of Terms 

Used in the Federal Budget Process, 

Funding estimates provided by HHS and VA 

suggest that there was spending on preventive health activities, but the 

funding estimates may not represent the amounts that were spent on the 

GAO-05-734SP (Washington, D.C.: September 

2005).

19When spending estimates were not readily available, HHS and VA provided available 

information for funding for those activities. Funding means budget authority, which is the 

authority provided by federal law to enter into financial obligations that will result in 

immediate or future outlays involving federal government funds.

HHS, VA, and DOD Do Not 

Track Department-wide 

Spending for Preventive 

Health Activities, but 

Provided a Mix of 

Information Related to 

Spending for Preventive 

Health Activities
 

Page 19 GAO-13-49 Preventive Health Activities

activities. For example, a department may not have spent all of its 

available funding for a preventive health activity.20

The most readily available information related to preventive health 

activities compiled by HHS is found in its annual crosscut briefing 

documents—documents that are used by HHS’s Office of the Secretary to 

make budget-related decisions and to answer questions from Congress 

and others related to the President’s annual budget request. ASFR 

compiles the information for these documents, but in its requests for 

information from the agencies for the documents, it has not provided 

agencies with a specific definition of activities to include in their 

prevention estimates nor specified a method for calculating an estimate. 

These annual crosscut briefing documents on prevention provide a mix of 

spending and funding estimates for prevention-related activities that 

include, but are not limited to, preventive health activities, and in recent 

years did not include estimates for CMS, which oversees health coverage 

programs for over 100 million individuals. In particular:

• The most recent annual crosscut briefing document on prevention

available at the time of our review included estimates of spending for 

one HHS agency and funding for nine HHS agencies for fiscal year 

2011.21

• The document did not include an estimate of spending for fiscal year 

2011 for CMS—that is, it did not include estimated spending for 

preventive health activities in Medicare, Medicaid, and the Children’s 

Health Insurance Program.22

 

20Funding represents an amount available at a particular time for spending (obligation and 

expenditure) for what may potentially be a range of activities including but not limited to 

preventive health activities. Funding amounts may not actually have been spent for the 

activities expected at the time the amounts were made available (for example, within 

applicable authority, amounts may have been subsequently transferred to other accounts 

or reprogrammed within an existing account in a departmental budget) and, even if spent 

for those activities, it may not be clear whether they were preventive in nature.

21The most recent crosscut briefing document on prevention in our review included the 

estimated amount of requested funding related to the President’s budget request for fiscal 

year 2012 and estimated spending on or funding for prevention for fiscal year 2011.

22The most recent estimate for CMS that was included in an HHS annual crosscut briefing 

document on prevention we reviewed was for fiscal year 2008. CMS’s estimated spending 

for prevention reported for that year was about $39 billion, but CMS noted that this 

estimate did not include preventive services covered by Medicare or Medicaid through 

managed care and included substantial amounts for treatment services provided.

HHS
 

Page 20 GAO-13-49 Preventive Health Activities

• The document included estimates for prevention-related activities that 

include, but are not limited to, clinical preventive services and 

community-oriented preventive health activities. That is, the document

included estimates of other prevention-related funding or spending 

such as emergency preparedness, environmental health, and 

occupational safety. For example, HHS’s prevention estimates 

included funding for the Food and Drug Administration’s (FDA) 

oversight of food safety, tobacco products, and medical products.23

The most recent HHS annual crosscut briefing document included in our 

review reported that for one agency (NIH), estimated spending on 

prevention for fiscal year 2011 was about $6 billion, and that estimated 

funding for prevention for nine agencies—ACF, AHRQ, AOA, CDC, FDA, 

HRSA, IHS, OASH, and SAMHSA—was about $18 billion that year. The 

annual crosscut briefing document did not include any estimated 

spending for fiscal year 2011 for CMS. (See app. II for more information 

on HHS’s prevention estimates.)

VA estimated spending of about $576 million for providing selected 

clinical preventive services in its VA medical facilities, including VA 

medical centers, outpatient clinics, and other facilities. VA’s estimated 

spending included UPSTSF-recommended services and other clinical 

preventive services that VA provided to its beneficiaries in outpatient 

settings in fiscal year 2011. The estimate also included estimated related 

spending for salaries and benefits for providers, administrative activities, 

and maintenance of facilities. VA did not include estimated spending for 

pharmaceutical drugs, services provided through VA’s purchased care 

program (which covers health care services provided to eligible veterans 

outside of VA when a VA facility is not available) or services provided in 

an inpatient setting. VA also provided its estimates of funding (totaling 

over $5 million) for its National Center for Health Promotion and Disease 

Prevention, which is responsible for developing the resources that 

support VA medical centers in providing community-oriented preventive 

health activities, and its Clinical Public Health Group’s communityoriented preventive health activities for fiscal year 2011. VA officials told 

us that individual VA medical facilities may have conducted additional 

community-oriented preventive health activities, such as taking measures 

 

23According to FDA, FDA activities are related to prevention, but do not include clinical 

preventive health activities or community-oriented preventive health activities.

VA
 

Page 21 GAO-13-49 Preventive Health Activities

to increase testing for HIV, that are not included in VA’s estimates. (See 

app. III for more information on VA’s estimates of spending and funding.)

DOD estimated spending about $1 billion to provide selected clinical 

preventive services, including (but not limited to) services recommended 

by the USPSTF, through its direct care and purchased care systems to 

active duty personnel, retired servicemembers, and other beneficiaries for 

fiscal year 2011. DOD also estimated spending about $407 million on 

some of its community-oriented preventive health activities and other 

activities (such as epidemiology) in DOD’s direct care system for fiscal 

year 2011. DOD’s spending estimates also have limitations. For example, 

because DOD’s estimates were limited to a review of purchased care 

claims and direct care data records, spending for some clinical preventive 

services—such as counseling about smoking cessation provided during a 

visit in which the patient received services for hypertension—is not 

included in the estimates. Also, while DOD’s estimates of spending 

include amounts for some community-oriented preventive health 

activities, they also include estimated spending on other activities (such 

as those related to drinking water safety and food and facility sanitation); 

DOD noted that it cannot separately identify spending specifically for the 

community-oriented preventive health activities. (See app. IV for more 

information on DOD’s estimates of spending.)

Articles in peer-reviewed publications and government and independent 

reports we reviewed identified some preventive health activities that may 

result in cost savings and reported that a larger number may be costeffective. The articles and reports we reviewed identified preventive 

health activities, such as childhood immunizations, workplace wellness 

programs, and disease screenings, that have been found in certain 

DOD

Some Preventive 

Health Activities May 

Be Cost Saving or 

Cost-Effective, but 

Multiple Factors 

Affect Estimates, and 

Key Data May Be 

Lacking 

Some Preventive Health 

Activities May Result in 

Cost Savings or May Be 

Cost-Effective
 

Page 22 GAO-13-49 Preventive Health Activities

circumstances to be cost saving—that is, the costs averted by the activity, 

such as future medical costs to treat a disease or condition, exceed the 

cost of implementing it.24 For example, according to one report that 

synthesized the results of three reviews of a number of clinical preventive 

services (the synthesis report), several clinical preventive services were 

estimated to be cost-saving by one or more of the three reviews.25 The 

report found that two preventive services—counseling on the use of lowdose aspirin to reduce coronary heart disease and childhood 

immunizations—were estimated to be cost-saving by all three reviews. 

The National Prevention Council’s National Prevention Strategy also 

reported that preventive health activities such as certain diabetes and 

tobacco interventions can result in cost savings.26 The articles and reports 

we reviewed, including the synthesis report, also identified a number of 

preventive health activities that, while not found to be cost saving, were 

estimated to be cost-effective—that is, they provided good value at low 

cost relative to alternative activities.27

 

24See, for example, J. T. Cohen, P. J. Neumann, and M. C. Weinstein, “Does Preventive 

Care Save Money? Health Economics and the Presidential Candidates,” New England 

Journal of Medicine, vol. 358, no. 7 (2008); K. Baicker, D. Cutler, and Z. Song, “Workplace 

Wellness Programs Can Generate Savings,” Health Affairs, vol. 29, no. 2 (2010); and 

R. S. Braithwaite and S. M. Mentor, “Identifying Favorable-Value Cardiovascular Health 

Services,” American Journal of Managed Care, vol. 17, no. 6 (2011).

The synthesis report identified 

several preventive health activities that were estimated by at least one of 

the reviews to be cost-effective, including counseling women to use 

calcium supplements, colorectal cancer screening, and hepatitis B 

screening in pregnant women. Colorectal cancer screening in adults 

25The report synthesized the findings of work by the National Commission on Prevention 

Priorities, the National Business Group on Health, and an academic researcher. According 

to the report, these three reviews were included because they all evaluated intervention 

costs and health benefits, quantified benefits (for example, in terms of QALYs gained), 

and were not limited to a particular intervention or to interventions for a particular 

subpopulation. J. T. Cohen and P. J. Neumann, The Cost Savings and Cost-Effectiveness 

of Clinical Preventive Care, Research Synthesis Report No. 18 (Princeton, NJ: Robert 

Wood Johnson Foundation, September 2009).

26National Prevention Council, National Prevention Strategy (Washington, D.C.: U.S. 

Department of Health and Human Services, Office of the Surgeon General, 2011). 

27See, for example, J. W. Kahende et al., “A Review of Economic Evaluations of Tobacco 

Control Programs,” International Journal of Environmental Research and Public Health, 

vol. 6 (2009) and R. L. Fleurence, C. P. Iglesias, and J. M. Johnson, “The Cost 

Effectiveness of Bisphophonates for the Prevention and Treatment of Osteoporosis,” 

Pharmacoeconomics, vol. 25, no. 11 (2007).
 

Page 23 GAO-13-49 Preventive Health Activities

50 years old and older was found to be cost-effective by all three 

reviews.28

Articles and reports we reviewed noted that there are important limitations 

associated with estimates of cost savings and cost-effectiveness. For 

example, some of the articles noted that preventive health activities that 

are found not to be cost saving or cost-effective may be less likely to be 

published in peer-reviewed journals.29 In addition, the synthesis report 

noted that there is no evidence that the findings included in the three 

reviews it examined are representative of the available literature on 

preventive health activities as a whole.

According to articles in peer-review publications and government and 

independent reports we reviewed, as well as researchers and federal 

officials we interviewed, each cost savings and cost-effectiveness 

estimate is affected by multiple factors. These include how an activity is 

targeted, the assumptions used in calculating cost savings and costeffectiveness estimates, and a lack of key data.

The targeting of a preventive health activity is an important factor 

affecting estimates of the cost savings or cost-effectiveness of that 

activity. Articles in peer-reviewed publications and reports, researchers 

we interviewed, and CDC officials reported that if a preventive health 

activity is targeted to a population at a higher risk of developing a specific 

disease, instead of being provided to the entire population regardless of 

their risk to develop the disease, the intervention will more likely result in 

cost savings or be cost-effective.30

 

28Articles in peer-reviewed publications and reports we reviewed also identified some 

preventive health activities that have been found not to be cost-effective. For example, 

one article estimated that screening for type 2 diabetes in all U.S. residents aged 45 years 

and older who have no other health factors, such as hypertension, was not cost-effective.

See R. Li et al., “Cost-Effectiveness of Interventions to Prevent and Control Diabetes 

Mellitus: A Systematic Review,” Diabetes Care, vol. 33, no. 8 (2010).

For example, CDC officials told us that 

29See, for example, R. Braithwaite, and S. Mentor. “Identifying Favorable-Value 

Cadiovacular Health Services,” American Journal of Managed Care, vol. 17, no. 6 (2011) 

and K. Baicker, D. Cutler, and Z. Song, “Workplace Wellness Programs Can Generate 

Savings,” Health Affairs, vol. 29, no. 2 (2010).

30In some cases, successful targeting can lead to additional costs. For example, if 

someone is screened for and has high blood pressure, the person may need to take 

medication or have additional tests for the rest of his or her life, which is an added cost.

Multiple Factors Affect 

Cost Savings and CostEffectiveness Estimates, 

and Key Data May Be 

Lacking 
 

Page 24 GAO-13-49 Preventive Health Activities

childhood vaccinations are often estimated to be cost saving and costeffective because the vaccines target a very specific, easy to identify, and 

high-risk population at relatively low financial costs. In addition, a CDC 

official noted that because the majority of children are at risk for 

developing the diseases targeted by the vaccinations, the vaccinations 

prevent a large number of diseases and thus avert the costs associated 

with the treatment of those diseases.31 As another example, a review of 

smoking cessation programs found that programs targeted to specific 

groups of smokers, such as pregnant women, were more cost-effective 

than those targeted at the general population of smokers. See table 3 for 

an illustration of how targeting can affect estimates of a preventive health 

activity’s cost-effectiveness—for example, targeting smokers on the basis 

of their levels of low-density lipoprotein (LDL) cholesterol and risk factors 

of developing heart disease.32 However, it can be difficult for physicians, 

for example, to know beforehand which patients are at a higher risk of 

developing a disease, in order to target a specific preventive health 

activity, as the Congressional Budget Office has reported.33 As a result, 

some preventive health activities may be provided to many patients, even 

those who will most likely not develop the disease, and costs can 

accumulate as the number of patients utilizing the preventive health 

activity increases.

 

31According to HHS officials, preventive health activities directed specifically to high-risk 

populations, such as children with developmental disabilities and special health care 

needs, may realize even greater cost savings and benefit.

32Estimates of cost-effectiveness are typically presented as a ratio of the net costs to the 

net outcomes of utilizing one preventive health activity over another.

33D. Elmendorf, Director, Congressional Budget Office, letter to the Honorable Nathan 

Deal, (Washington, D.C.: Aug. 7, 2009). This letter is available online at 

https://www.cbo.gov/publication/20967. This letter responds to a question concerning the 

Congressional Budget Office’s analysis of the budgetary effects of proposals to expand 

governmental support for preventive medical care and wellness services. In making its 

estimates of the budgetary effects of expanded governmental support for preventive care, 

CBO takes into account any estimated savings accruing within specified time frames that 

would result from greater use of such care as well as the estimated costs of that additional 

care. CBO’s estimates take into account that preventive care may reduce spending for an 

individual and that, to avert one case of acute illness, it is often necessary to provide 

preventive care to many patients, most of whom would not have suffered the illness 

anyway.
 

Page 25 GAO-13-49 Preventive Health Activities

Table 3: Effect of Targeting on Cost-Effectiveness Ratio for Selected Preventive Health Activities

Preventive health activity Compared to Target population

Cost-effectiveness ratio 

(dollars)

Using a statin to prevent 

heart disease

a

Diet-based prevention Male smokers with very high low-density 

lipoprotein (LDL) cholesterol,

b $54,000/QALY

high blood 

pressure, age 35-44 years

Using a statin to prevent 

heart disease

Diet-based prevention Male smokers with high LDL cholesterol,

b 100,000/QALY

high blood pressure, age 35-44 years

Using alendronate to prevent 

fragility fractures

No intervention Postmenopausal women with bone marrow 

density 2.4 standard deviations below 

normal, no vertebral abnormalities, age 60

37,482/QALY

Using alendronate to prevent 

fragility fractures

No intervention Postmenopausal women with bone marrow 

density 1.0 standard deviation below 

normal, no vertebral abnormalities, age 80

166,219/QALY

Source: GAO summary of information from published research.

Notes: Data are from L. A. Prosser et al., “Cost-Effectiveness of Cholesterol-Lowering Therapies 

According to Selected Patient Characteristics,” Annals of Internal Medicine, vol. 132, no. 10 (2000) 

and R. L. Fleurence, C. P. Iglesias, and J. M. Johnson, “The Cost Effectiveness of Bisphophonates 

for the Prevention and Treatment of Osteoporosis,” Pharamcoeconomics, vol. 25, no. 11 (2007).

a

The cost-effectiveness ratio represents the cost per quality-adjusted life-year (QALY) that would be 

added by the activity. A year in perfect health is worth 1 QALY, and a year in less than perfect 

health—that is, with any adverse condition—is generally worth between 0 and 1 QALY. The 

preventive health activity with the lower cost-effectiveness ratio is preferred because it costs less to 

achieve the health outcome. For example, if the cost-effectiveness ratio of one preventive health 

activity is $80,000/QALY and that of another activity is $20,000/QALY, the activity with the 

$20,000/QALY cost-effectiveness ratio would be preferred.

b

Also affecting an estimate of a preventive health activity’s cost savings or 

cost-effectiveness are the assumptions used in calculating the estimate, 

such as those regarding the effectiveness of the activity, perspective of 

the study, and accounting for future medical technology. For example, in 

modeling the cost-effectiveness of a vaccine, a researcher might assume 

that the vaccine is 90 percent effective at preventing a disease in the 

model, but the actual effectiveness of the vaccine may not be known.

The National Heart, Lung, and Blood Institute (NHLBI) categorizes LDL cholesterol between 160 

to189 milligrams per deciliter as high. Very high LDL cholesterol is 190 milligrams per deciliter or 

higher. NHLBI categorizes high blood pressure as a diastolic blood pressure of 95 millimeters of 

mercury or higher. The target population also has low levels of “good” cholesterol, or high-density 

lipoproteins.

• Assumptions about the effectiveness of the activity. Assumptions 

about the effectiveness of an activity can affect estimates of cost 

savings or cost-effectiveness. For example, researchers reviewed 

multiple estimates of the cost-effectiveness of vaccination against 

human papillomavirus (HPV) and found that varying the assumptions 

for the vaccine’s effectiveness, the number of years the vaccine would 

provide protection against HPV, or the years of costs for additional 
 

Page 26 GAO-13-49 Preventive Health Activities

screening and testing for HPV produced estimates of the vaccine’s 

cost-effectiveness ranging from $20,600 per QALY to more than 

$3.5 million per QALY.34

• The perspective of a study. The perspective of a study—that is, who is 

receiving the benefit or bearing the cost—can affect an estimate of the 

extent to which a preventive health activity is cost saving or costeffective. Many studies are conducted from the perspective of the 

entity providing the preventive health activity, such as an employer or 

hospital system, so the costs and benefits of an activity to an 

individual consumer or others may not be considered. For example, a 

review of multiple estimates of the cost-effectiveness of HIV 

screenings noted that a study conducted from the perspective of the 

entity funding the activity may not incorporate certain costs, such as 

treatment costs, or long-term benefits, such as extension of life 

expectancy. As a result, the study may not reflect all possible costs 

and savings that could result from a preventive health activity.

• Assumptions about technology. Assumptions about future medical 

technology may also affect a cost saving and cost-effectiveness

estimate about a preventive health activity. A CDC official told us that 

in projecting the costs and benefits of an activity, the typical 

assumption is that medical technology will be and cost the same 

years into the future, even though technology, which can alter the 

costs and benefits of an activity, can change rapidly over time.

Difficulties in estimating cost savings and cost-effectiveness for a 

preventive health activity, including the need to make assumptions, can 

arise from a lack of key data. For example, ACIP officials said a challenge 

in determining the cost savings or cost-effectiveness of vaccines is that 

data needed for the analysis, such as the actual price of a new vaccine, 

are not available at the time they make a recommendation. Similarly, data 

on outcomes resulting from a preventive health activity are not available 

 

34In a study of HPV vaccine, when the researcher assumed the vaccine was 90 percent 

effective and provided lifetime protection at a cost of $377 per 3-shot series, it produced a 

cost-effectiveness ratio of $24,300 per QALY. When the assumptions were changed to 

assume 100 percent effectiveness, the cost-effectiveness improved to $20,600 per QALY. 

When researchers used a model with other assumptions for the HPV vaccination strategy 

such as vaccination at age 12 years and preventive screenings—annual cervical 

screening and liquid-based cytology testing starting at age 18—and compared it to the 

next-best strategy, which was similar to this strategy but did not include liquid-based 

cytology, cost-effectiveness worsened to more than $3.5 million per QALY.
 

Page 27 GAO-13-49 Preventive Health Activities

for many diseases. A CDC official stated that when a community-oriented 

preventive health activity has not been found to be cost-effective, this is 

often due to a lack of sufficient data needed to conduct cost-effectiveness 

analysis rather than evidence that the activity is not cost-effective. In 

some cases, the outcome measures used to study the effects of a 

preventive health activity make determining cost-effectiveness difficult.

For example, instead of using an outcome measure such as the cost per 

QALY, a study evaluating efforts to increase vaccination may measure 

the cost per child immunized. Additional economic modeling would have 

to occur, and assumptions be made, in order to convert the data to cost 

per QALY. Researchers also noted that some studies that focus on the 

effectiveness of preventive health activities do not report costs of the 

preventive health activity. A research article that reviewed studies that 

estimated cost savings resulting from workplace wellness programs 

reported that nearly one-third of the studies in its review did not report 

program costs.35 According to CDC officials, CDC is taking steps to 

collect data for cost-effectiveness analyses for programs related to 

preventive health activities for which relevant data have been lacking. In 

addition, the Institute of Medicine conducted a study to develop a 

framework for assessing community-oriented preventive health activities. 

This framework considers, among other things, the sources of data that 

are available and needed for analysis.36

 

35K. Baicker, D. Cutler, and Z. Song, “Workplace Wellness Programs Can Generate 

Savings,” Health Affairs, vol. 29, no. 2 (2010).

36For the report on this study, see the Institute of Medicine website 

(http://www.iom.edu/Activities/PublicHealth/CommunityPrevention.aspx, accessed 

Nov. 14, 2012). 
 

Page 28 GAO-13-49 Preventive Health Activities

Data for international comparisons of countries’ spending specifically for 

preventive health activities are not available. Instead, the most readily 

available data is a category of OECD health data called “prevention and 

public health services,”37 which combines spending on certain clinical 

preventive services and community-oriented preventive health activities, 

such as vaccination programs, and public health activities, such as 

disease surveillance and blood banks.38 On the basis of these data, the 

United States ranked 8th among 23 OECD member countries in the 

percentage of total health care spending reported for prevention and 

public health services (see fig. 2). In 2010, U.S. spending on prevention 

and public health services was about $88.4 billion, or 3.5 percent of total 

U.S. health care spending of $2.5 trillion—a rate that has remained 

relatively steady since 2001.39

 

37OECD defines prevention and public health services as services designed to enhance 

the health status of the population, as opposed to curative services, which repair health 

dysfunction.

38These data are not comparable to the spending and funding estimates provided by 

HHS, VA and DOD. For example, OECD’s data pertaining to the United States do not 

capture spending for certain clinical preventive services provided by HHS, VA, and DOD, 

and combine federal spending with state and local spending.

39As of July 2012, OECD posted 2010 health spending data from 28 of its member 

countries, and posted data for the OECD category of prevention and public health 

services from 23 of these countries. For the most recent data, see the OECD.Stat 

database available on OECD’s website 

(http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT#, accessed July 12, 

2012). In order to compare spending, OECD converts countries’ health expenditures to a 

common currency (e.g., U.S. dollars) and makes adjustments to take account of the 

different purchasing power of the national currencies.

International Data on 

Preventive Health 

Activities Are Not 

Available, but United 

States Ranks Eighth 

in OECD Category 

That Combines 

Spending on 

Prevention and Public 

Health Services
 

Page 29 GAO-13-49 Preventive Health Activities

Figure 2: Spending for Prevention and Public Health Services as a Percentage of Total Health Spending, by OECD Member 

Country, 2010

Note: This figure presents a summary of 2010 data on health care spending, including spending for 

the 23 OECD member countries that submitted data to OECD on the category of prevention and 

public health services.

U.S. spending in the OECD category of prevention and public health 

services also ranked third highest as a percentage of gross domestic 

product among the 23 countries reporting 2010 data to OECD. 

Specifically, total U.S. spending on prevention and public health services 

was 0.6 percent of U.S. gross domestic product (about $88.4 billion for 

prevention and public health spending out of a total gross domestic 

product of about $14.4 trillion). Canada and New Zealand spent a higher 

percentage of gross domestic product on prevention and public health 

services (see fig. 3). U.S. rankings in OECD’s international comparisons 

of spending on prevention and public health services as a percentage of 

gross domestic product have been generally constant since 2001.
 

Page 30 GAO-13-49 Preventive Health Activities

Figure 3: Spending for Prevention and Public Health Services as a Percentage of Gross Domestic Product, by OECD Member 

Country, 2010

Note: This figure presents a summary of 2010 data on health care spending, including spending for 

the 23 OECD member countries that submitted data to OECD on the category of prevention and 

public health services.

U.S. spending per capita on prevention and public health services was 

$286.11, second highest, behind Canada (see fig. 4). U.S. rankings in 

OECD’s international comparisons of spending on prevention and public 

health services per capita have also been fairly constant since 2001.
 

Page 31 GAO-13-49 Preventive Health Activities

Figure 4: Spending for Prevention and Public Health Services per Capita, by OECD Member Country, 2010

Note: This figure presents a summary of 2010 data on health care spending, including spending for 

the 23 OECD member countries that submitted data to OECD on the category of prevention and 

public health services. OECD adjusted spending per capita for purchasing power parity.

While OECD’s data are frequently used to make international 

comparisons, there are limitations in using OECD’s data to make 

international comparisons on spending included in the prevention and 

public health services category. For this category, OECD requested that 

countries submit data that include spending on certain types of preventive 

health and public health activities, such as maternal and child health 

activities and school health services. However, member countries do not 

always consistently report spending for this category. For example, the 

data submitted by the United States reflect federal, state, and local 

government spending for maternal and child health activities, school 

health services, and certain other preventive health and public health 

activities, but do not include government or private sector spending on 
 

Page 32 GAO-13-49 Preventive Health Activities

clinical preventive services provided in physicians’ offices or hospitals.40

In contrast, the data submitted by other OECD countries may include 

amounts spent on preventive health activities by the private sector in 

physicians’ offices or hospitals. While there are known limitations to using 

OECD data, experts we interviewed reported that the OECD data are the 

best available data for comparing U.S. spending on prevention and public 

health services with that of other countries, and the data have been 

frequently used to make international comparisons.41 An OECD official 

told us that OECD is taking steps to improve the comparability of the data 

in the future by, for example, providing clarity about the criteria that 

should be used by member countries to report prevention-related data. 

The official noted that it will be a couple of years before these data are 

available.

Preventive health activities have received attention over the past several 

years for their potential impact on health care spending or health 

outcomes. However, HHS, VA, and DOD do not track department-wide 

spending on preventive health activities, and identifying spending on such 

activities is challenging because they are often integrated with other 

activities. Further, estimating cost savings and cost-effectiveness of 

preventive health activities is difficult because of the multiple factors that 

can affect these estimates, including the need to make assumptions and 

a lack of key data. These methodological challenges, as well as a lack of 

widespread agreement on what constitutes a preventive health activity, 

are important considerations that affect the completeness and precision 

of available information on preventive health activities.

 

40U.S. spending for health care services provided in physicians’ offices and hospitals, 

including both treatment services and preventive health activities, are included in a 

different OECD spending category. Private sector spending in OECD’s prevention and 

public health services category includes privately funded occupational health care and 

prevention and public health services provided by charities, other nongovernmental 

organizations, and voluntary organizations.

41For example, the Institute of Medicine used OECD data to compare the United States to 

other nations in per capita health expenditures and health outcomes, such as infant 

mortality, for a recent report on public health financing. See Institute of Medicine, For the 

Public’s Health: Investing in a Healthier Future (Washington, D.C.: The National 

Academies Press, 2012).

Concluding 

Observations 
 

Page 33 GAO-13-49 Preventive Health Activities

HHS, VA, and DOD reviewed a draft of this report. DOD concurred with 

the draft report. HHS and VA provided technical comments, which we 

incorporated as appropriate.

As agreed with your offices, unless you publicly announce its contents 

earlier, we plan no further distribution of this report until 30 days from the 

report date. At that time, we will send copies of this report to the 

Secretary of Health and Human Services, Secretary of Veterans Affairs, 

Secretary of Defense, and interested congressional committees. In 

addition, the report will be available at no charge on the GAO website at 

http://www.gao.gov.

If you or your staff have any questions regarding this report, please 

contact me at (202) 512-7114 or iritanik@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. GAO staff who made key contributions to this 

report are listed in appendix V.

Katherine Iritani

Director, Health Care

Agency Comments
Appendix I: Requirements Related to 

Preventive Health Activities in the Duncan 

Hunter National Defense Authorization Act

Page 34 GAO-13-49 Preventive Health Activities

The Duncan Hunter National Defense Authorization Act for Fiscal Year 

2009 requires DOD to reduce beneficiary cost sharing for preventive 

health activities and undertake certain preventive health activities,1

• Section 711: Waiver of Copayments for Preventive Services for 

Certain TRICARE Beneficiaries. Requires the Secretary of Defense to 

promulgate rules eliminating beneficiary cost-sharing previously 

associated with certain preventive services (such as colorectal cancer 

screening, breast cancer screening, cervical cancer screening, 

prostate cancer screening, annual physical exams, and vaccinations) 

for beneficiaries enrolled in TRICARE’s fee-for-service program who 

are not eligible for Medicare. Beneficiaries enrolled in TRICARE’s 

managed care option already received these services with a zero cost 

share. In December 2011, DOD issued a final rule implementing this 

provision by eliminating beneficiary cost sharing for certain preventive 

services provided on or after October 14, 2008.

as 

follows:

2

• Section 712: Military Health Risk Management Demonstration Project. 

Requires the Secretary of Defense to conduct a demonstration project 

designed to evaluate the efficacy of providing incentives to encourage 

healthy behaviors on the part of non-Medicare-eligible retired 

beneficiaries, including their dependents, enrolled in TRICARE’s 

managed care option. Authorizes the Secretary to offer incentives to 

encourage participation in the demonstration project; accordingly, 

beneficiaries were offered a monetary incentive award for full 

compliance with the demonstration’s requirements. Single participants 

would receive $115, and participants with family members would 

receive $230. In its interim report submitted to Congress in August 

2011, DOD reported that it began implementing the demonstration 

project in October 2010, and that it was monitoring patients for 

compliance from January 2011 through December 2011. According to 

DOD, incentive payments were disbursed in June 2012. DOD also 

reported that the department had been collecting data to estimate 

costs avoided as a result of decreased health risk conditions and that 

results would be included in a final report to Congress, which DOD 

anticipates submitting by December 2012.

 

1

Pub. L. No. 110-417, §§ 711-714, 122 Stat. 4356, 4500-04 (2008).

2

76 Fed. Reg. 81368 (Dec. 28, 2011) (to be codified at 32 C.F.R. §§ 199.4 and 199.17).

Appendix I: Requirements Related to 

Preventive Health Activities in the Duncan 

Hunter National Defense Authorization Act 
Appendix I: Requirements Related to 

Preventive Health Activities in the Duncan 

Hunter National Defense Authorization Act

Page 35 GAO-13-49 Preventive Health Activities

• Section 713: Smoking Cessation Program under TRICARE. Requires 

the Secretary of Defense to establish a smoking cessation program to 

be available to TRICARE beneficiaries who are not eligible for 

Medicare. Requirements for the program include providing no-cost, 

smoking cessation pharmaceuticals; counseling; access to a toll-free 

24/7 quit line with counseling; and access to printed and Internetbased tobacco cessation material. According to DOD, program 

implementation planning has been ongoing. DOD issued a proposed 

rule in September 2011.3 As of July 2012, a final rule had not been 

published. DOD also reported that access to printed materials and 

web-based information on smoking cessation has been available to 

TRICARE beneficiaries, and that a final status report to Congress will 

be submitted following full implementation of the Smoking Cessation 

Program under TRICARE.

• Section 714: Preventive Health Allowance. Requires the Secretary of 

Defense to conduct a demonstration project to evaluate whether 

providing an annual allowance (called a preventive health services 

allowance) would increase the use of preventive health services by 

members of the Armed Forces and their family members. Preventive 

services under this section included colorectal, breast, cervical, and 

prostate cancer screening; an annual physical exam; an annual dental 

exam; weight and body mass screening, and vaccinations. The 

demonstration, which began on December 1, 2009, was limited to 

1,500 members from each of the Army, Navy, Air Force, and Marine 

Corps. The amount of the allowance for compliance with the required 

preventive health services was set at $500 for single participants, and 

$1,000 for those enrolled with dependents, and the demonstration 

ended December 31, 2011. Although the final report was due no later 

than March 31, 2012, the department anticipates submitting the final 

report to Congress by December 2012 to allow for complete 

collection, review, and analysis of the data.

 

3

76 Fed. Reg. 58199 (Sept. 20, 2011) (to be codified at 32 C.F.R. §§ 199.4 and 199.21).
Appendix II: Department of Health and Human 

Services Estimates of Spending and Funding 

for Preventive Health Activities

Page 36 GAO-13-49 Preventive Health Activities

The Department of Health and Human Services (HHS) does not track 

department-wide spending on preventive health activities, but the 

department provided us with a mix of information related to spending for 

preventive health activities and noted limitations associated with the 

information. For nine HHS agencies, HHS provided agency-level 

estimates of funding for prevention-related activities, which include but 

are not limited to preventive heath activities (clinical preventive services 

or community-oriented preventive health activities).1

HHS’s estimates of funding for most of its agencies and estimates of 

spending for NIH were prepared by the department as part of its annual 

crosscut briefing document on prevention.

For the National 

Institutes of Health (NIH), HHS provided estimated spending on 

prevention-related activities.

2 HHS’s Office of the Secretary 

uses this document to make budget-related decisions and answer 

questions from Congress and others related to the President’s annual 

budget request.3

 

1

Funding means budget authority, which is the authority provided by federal law to enter 

into financial obligations that will result in immediate or future outlays involving federal 

government funds. See GAO, A Glossary of Terms Used in the Federal Budget Process, 

In its fiscal year 2012 crosscut briefing document

(related to the President’s budget request for fiscal year 2012), HHS 

GAO-05-734SP (Washington, D.C.: September 2005). Funding represents an amount 

available at a particular time for spending (obligation and expenditure) for what may 

potentially be a range of activities including but not limited to preventive health activities.

Funding amounts may not actually have been spent for the activities expected at the time 

the amounts were made available (for example, within applicable authority, amounts may 

have been subsequently transferred to other accounts or reprogrammed within an existing 

account in the department’s budget) and, even if spent for those activities, it may not be 

certain that they were preventive in nature. In some instances, HHS agencies reported 

budget authority, transfers, and user fees available for obligation separately. We report 

information as provided to us by HHS agencies. 

2

HHS does not define prevention for the purposes of its annual crosscut briefing 

documents on prevention. In addition to preventive health activities (clinical preventive 

services and community-oriented preventive health activities), HHS may include in 

prevention activities such as emergency preparedness, environmental health, and 

occupational safety activities. HHS, VA, and DOD participate in the National Prevention 

Council, which consists of 17 departments, agencies, and offices across the federal 

government—representing sectors such as housing, transportation, education, 

environment, and defense—that promote prevention and wellness. Information about the 

council is available at http://www.healthcare.gov/prevention/nphpphc (accessed Aug. 30, 

2012).

3

HHS also prepares crosscut briefing documents that estimate department-wide funding 

for other health-related topics, such as behavioral health, patient safety, and tobacco.

Appendix II: Department of Health and 

Human Services Estimates of Spending and 

Funding for Preventive Health Activities
Appendix II: Department of Health and Human 

Services Estimates of Spending and Funding 

for Preventive Health Activities

Page 37 GAO-13-49 Preventive Health Activities

combined its fiscal year 2011 funding estimates for prevention for nine 

HHS agencies with NIH’s spending (specifically, obligations) estimate for 

prevention and reported a total of about $24 billion. However, this 2011 

estimate excluded the Centers for Medicare & Medicaid Service’s (CMS) 

Medicare and Medicaid programs and the Children’s Health Insurance 

Program.4

The HHS annual crosscut briefing documents on prevention are limited in 

multiple ways. First, HHS officials told us that each HHS agency used its

own criteria to identify prevention funding—that is, HHS agencies did not 

use a uniform definition of prevention. As a result, activities that are 

similar in nature may have been included in one but not in another 

agency’s estimate. Second, the agency estimates do not always 

represent the same kind of information. For example, funding estimates 

for most agencies represent budget authority, but estimates as reported 

for CDC represent budget authority, transfers, and user fees that the 

agency had authority to obligate as separate categories. Third, criteria 

used by an agency to identify the activities to include in its prevention 

estimate may not have always been consistently applied by that agency. 

The annual crosscut briefing document included the following estimates 

for fiscal year 2011 for 10 HHS agencies:

The fiscal year 2011 estimate that included funding for 

programs administered by nine HHS agencies and spending for programs 

administered by NIH included clinical preventive services and communityoriented preventive health activities, as well as other prevention-related 

activities that HHS agencies did not identify as clinical preventive services 

or community-oriented preventive health activities. For example, HHS 

included in its prevention estimates funding for Food and Drug 

Administration (FDA) oversight of drugs and medical devices.

• Administration for Children and Families (ACF). The document

included estimated funding of $330 million for prevention.

• Agency for Healthcare Research and Quality (AHRQ). The document

included estimated funding of $28 million for prevention.

 

4

The most recent estimate for CMS that was included in an HHS annual crosscut briefing 

document on prevention we reviewed was for fiscal year 2008. CMS’s estimated spending 

for prevention reported for that year was about $39 billion, but CMS noted that this 

estimate did not include preventive services covered by Medicare or Medicaid through 

managed care and included substantial amounts for treatment, rather than prevention.
Appendix II: Department of Health and Human 

Services Estimates of Spending and Funding 

for Preventive Health Activities

Page 38 GAO-13-49 Preventive Health Activities

• Administration on Aging (AOA).5 The document included estimated 

funding of $24 million for prevention.

• Centers for Disease Control and Prevention (CDC). The document

included estimated funding of $11.4 billion for prevention. The 

$11.4 billion estimate includes budget authority, transfers, and user 

fees that the agency had authority to obligate as separate categories.6

• FDA. The document included estimated funding of $3 billion for 

prevention. The estimate represents user fees that the agency had 

authority to obligate and other budget authority as separate categories 

and, according to FDA officials, excludes infrastructure funding such 

as funding for facilities and rent-related activities. According to FDA, 

the agency’s activities included in its estimate do not include clinical 

preventive services or community-oriented preventive health activities.

• Health Resources and Services Administration (HRSA). The 

document included estimated funding of $1.3 billion for prevention. 

Although HRSA’s estimate included multiple programs administered 

by the agency, the estimate did not include all of the agency’s funding 

for prevention. According to HRSA officials, HRSA’s estimate included 

funding for a program (the National Health Service Corps) that places 

primary care providers in underserved areas, but did not include any 

of the funding for its Health Center Program, which also provides 

primary care services in underserved areas. According to HRSA 

officials, the Health Center Program will be included in the prevention 

estimates in the future.

• Indian Health Service (IHS). The document included estimated 

funding of $953 million for prevention.

 

5

In April 2012, HHS created the Administration for Community Living (ACL) by combining 

AOA, the Office on Disability, and the Administration on Intellectual and Developmental 

Disabilities.

6

This estimate consisted of all of CDC’s available funding for fiscal year 2011. However, at 

the time the estimate was compiled, the agency was operating under a series of 

continuing resolutions. CDC indicated that subsequent enactment of the fiscal year 2011 

full-year continuing resolution resulted in a downward adjustment for CDC’s funding for 

fiscal year 2011, to about $11.0 billion.
Appendix II: Department of Health and Human 

Services Estimates of Spending and Funding 

for Preventive Health Activities

Page 39 GAO-13-49 Preventive Health Activities

• NIH. Instead of estimated funding, the document included estimated 

spending—specifically, obligations—for prevention of $6 billion.7

• Office of the Assistant Secretary for Health (OASH). The document

included estimated funding of $255 million for prevention.

• Substance Abuse and Mental Health Services Administration 

(SAMHSA). The document included estimated funding of $719 million 

for prevention.

 

7

NIH publishes information on spending for prevention on its website 

(http://report.nih.gov/categorical_spending.aspx). 
Appendix III: Department of Veterans Affairs 

Estimates of Spending and Funding for 

Preventive Health Activities

Page 40 GAO-13-49 Preventive Health Activities

The Department of Veterans Affairs (VA) does not specifically track 

department-wide spending on preventive health activities, but it provided 

estimates of spending and funding. VA estimated its spending on certain 

clinical preventive services for VA beneficiaries, and estimated its funding 

for certain community-oriented preventive health activities.

VA estimated that its spending—specifically, its obligations—for providing 

certain clinical preventive services to eligible veterans and nonveterans in 

an outpatient setting in fiscal year 2011 totaled about $576 million.1 VA’s 

fiscal year 2011 estimate includes estimated obligations for providing 

clinical preventive services in all VA medical facilities, including VA 

medical centers, outpatient clinics, and other facilities.2 Examples of the 

clinical preventive services included in the estimate are dental cleaning; 

depression screening; post-traumatic stress screening; immunizations; 

diabetes screening; hypertension screening; tobacco use screening and 

counseling; and screenings for breast cancer, cervical cancer, and 

colorectal cancer. The Veterans Health Administration’s (VHA) Allocation 

Resource Center3

 

1

According to VA, the estimates it provided are the department’s estimated obligations, 

and the estimated amount is about 2.2 percent of the total obligations (about $26 billion) of 

providing outpatient clinical services through VA facilities in fiscal year 2011. 

reported that the clinical preventive services included 

in the analysis were identified by VA’s National Center for Health 

Promotion and Disease Prevention. The services included (but were not 

limited to) those recommended by the U.S. Preventive Services Task 

Force (USPSTF).

2

VA included in its estimate the estimated obligations associated with clinical preventive 

services provided in outpatient settings in VA facilities, including estimated obligations for 

salaries and benefits for providers, administrative activities, and maintenance of facilities. 

VA did not include estimated obligations for pharmaceutical drugs, services provided for 

purchased care (provided to eligible veterans outside of VA when a VA facility is not 

available) or services provided in an inpatient setting. To estimate obligations, VA used 

the Decision Support System, which is an activity-based cost accounting system that 

generates estimates of the cost of individual VA hospital stays and health care 

encounters. If the first procedure or diagnosis in a VA beneficiary’s encounter was a 

clinical preventive service, then VA estimated that 90 percent of the cost of the encounter 

was for preventive health activities. If the procedure or diagnosis was not listed first, then 

VA estimated that 25 percent of the cost of the encounter was for preventive health 

activities. According to VA, nearly two-thirds of the encounters used for the estimate had 

preventive services listed first.

3

VHA administers VA’s health care system, and VHA’s Allocation Resource Center is 

responsible for developing, implementing, and maintaining management information 

systems that provide data for VHA’s budget process.

Appendix III: Department of Veterans Affairs 

Estimates of Spending and Funding for 

Preventive Health Activities
Appendix III: Department of Veterans Affairs 

Estimates of Spending and Funding for 

Preventive Health Activities

Page 41 GAO-13-49 Preventive Health Activities

VA reported limitations associated with its estimated obligations for 

providing clinical preventive services in its facilities. VA reported that it 

cannot determine when certain services included in the estimate, such as 

colonoscopies, were provided for preventive purposes or for treatment 

purposes. In addition, VA could not identify the provision of certain clinical 

preventive services, such as sexually transmitted infections counseling for 

adults at increased risk, and therefore these services were not included in 

the estimates.

VA also reported that fiscal year 2011 funding for its National Center for 

Health Promotion and Disease Prevention—which is responsible for 

developing the resources that support VA medical centers in providing 

community-oriented preventive health activities—totaled about $4 million 

(out of its fiscal year 2011 total budget authority for health care of about 

$50.7 billion). The funding amount includes all of the center’s activities, 

such as the MOVE! Weight Management Program. VA also reported that 

funding for its Clinical Public Health Group’s community-oriented 

preventive health activities in fiscal year 2011 totaled about $1.4 million. 

Examples of the Clinical Public Health Group’s activities include the HIV 

Prevention Handbook, the VA Flu Manual, VA’s Infection: Don’t Pass It 

On campaign, and developing and printing tobacco cessation educational 

materials. VA officials told us that individual VA medical facilities may 

have conducted additional community-oriented preventive health 

activities, such as measures to increase testing for HIV, that are not 

included in VA’s estimates.
Appendix IV: Department of Defense Estimates 

of Spending for Preventive Health Activities

Page 42 GAO-13-49 Preventive Health Activities

The Department of Defense (DOD) does not specifically track 

department-wide spending on preventive health activities, but it estimated 

its spending for providing certain clinical preventive services through its 

direct care and purchased care systems. In addition, DOD estimated its 

spending on some of the community-oriented preventive health activities 

and other activities such as epidemiology provided in its direct care 

system. 

DOD estimated that its spending for providing selected clinical preventive 

services, including but not limited to services recommended by the U.S. 

Preventive Services Task Force (USPSTF), through its direct care and 

purchased care systems totaled about $1 billion in fiscal year 2011 and 

about $969 million in fiscal year 2010.1

Table 4: DOD Estimates of Spending for Providing Clinical Preventive Services in 

DOD’s Direct Care and Purchased Care Systems, Fiscal Years 2010 and 2011

Examples of clinical preventive 

services included in the estimates are vision and dental screenings; 

immunizations; hypertension screening; cardiovascular disease 

screening; and screenings for breast cancer, cervical cancer, and 

colorectal cancers. In each year, more than three-fourths of DOD’s 

estimated spending for clinical preventive services was spent in its direct 

care system. (See table 4.)

DOD system 2010 2011 Total

Direct care $751,943,686 $816,160,851 $1,568,104,537

Purchased care 217,512,837 266,147,691 $483,660,527

Total $969,456,522 $1,082,308,542 $2,051,765,064

Source: GAO summary of DOD estimates.

Note: Pharmacy costs, laboratory costs, and facility costs are not included in the purchased care 

estimates of spending. Rows and columns may not total due to rounding.

 

1

DOD estimated spending for providing selected clinical preventive services in its direct 

care system using encounter data from the Comprehensive Ambulatory/Professional 

Record dataset and in its purchased care system using encounter data from the TRICARE 

Encounter Data Non-Institutional Data dataset. Both datasets are contained in DOD’s 

Military Health System Data Repository. DOD’s spending estimates are based on 

estimated costs using a relative value unit that adjusted for quantity and provider 

specialties.

Appendix IV: Department of Defense 

Estimates of Spending for Preventive Health 

Activities
Appendix IV: Department of Defense Estimates 

of Spending for Preventive Health Activities

Page 43 GAO-13-49 Preventive Health Activities

DOD reported limitations associated with its estimated spending for 

providing clinical preventive services through its direct care and 

purchased care systems.2

DOD also estimated its spending—specifically, obligations—on some of 

its community-oriented preventive health activities and other activities 

such as epidemiology provided in its direct care system. DOD’s estimated 

obligations for these activities totaled about $326 million in fiscal year 

2009, about $379 million in fiscal year 2010, and about $407 million in 

fiscal year 2011. DOD included some community-oriented preventive 

health activities coordinated by DOD’s TRICARE Management Activity in 

these estimates. Specifically, the estimates included DOD’s “That Guy” 

alcohol education campaign and the Quit Tobacco—Make Everyone 

Proud program (a tobacco cessation marketing and education campaign), 

as well as other activities such as drinking water safety, and food and 

facility sanitation. DOD noted that it cannot separately identify spending 

specifically for the community-oriented preventive health activities.

Because its estimates were limited to a review 

of purchased care claims and direct care data records, the costs for some 

clinical preventive services are not included in the spending estimates. 

For example, a patient who receives services for hypertension may also 

receive counseling about smoking cessation from the provider during a 

visit. The counseling would not be captured in the data used for DOD’s 

estimates. Also, pharmacy costs, laboratory costs, and facility costs in the 

military treatment facilities are included in the direct care spending 

estimates but not in the purchased care spending estimates.

 

2

According to DOD, the total costs of providing clinical services to beneficiaries through its 

purchased care system in fiscal year 2011 represented 48 percent of its total costs for 

providing clinical services. 
Appendix V: GAO Contact and Staff 

Acknowledgments

Page 44 GAO-13-49 Preventive Health Activities

Katherine Iritani, (202) 512-7114 or iritanik@gao.gov

In addition to the contact named above, Kim Yamane, Assistant Director; 

George Bogart; Hernan Bozzolo; Cathy Hamann; and Toni Harrison 

made key contributions to this report.

Appendix V: GAO Contact and Staff 

Acknowledgments 

GAO Contact 

Staff 

Acknowledgments 

(290979)
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