Public Health Implications of Government Spending Reductions
Authors: Steven H. Woolf
Journal: JAMA (2011)

ACROSS THE UNITED STATES, CONCERNS OVER BUDget deficits and a weak economy have prompted federal, state, and local governments to propose controversial spending reductions to balance their budgets. Debates and protests incited by these decisions dominate the news, but what is their relevance to medicine? The reflexive answer might be that government spending policies are relevant if they compromise health care services, essential public health programs, or biomedical research. However, the biggest threat to public health may come from funding cuts outside the health sector. Namely, budget decisions that affect basic living conditions—removing opportunities for education, employment, food security, and stable neighborhoods— could arguably have greater disease significance than disruptions in health care. Health status is determined by more than health care. Education, income, and the neighborhood environment exert great influence on the development of disease— perhaps more than interventions by physicians or hospitals. Consider the role of education. In 2007, adults with a bachelor’s degree were 4 times less likely to report fair or poor health than those without a high school education. The prevalence of diabetes among adults without a high school diploma was 13.2%, more than double the prevalence among adults with a bachelor’s degree (6.4%). In 2008-2009, the risk of stroke was 80% higher among adults who lacked a high school diploma than among those with some college education. At age 25, life expectancy is at least 5 years longer among college graduates than among those who did not complete high school. Multiple factors explain the health disparity associated with education. Educational attainment is inversely associated with smoking and obesity, but it is also a pathway to better jobs, benefits (including health insurance), and financial security—each of which conveys health advantages. Families with financial insecurity face hardships that often take priority over health concerns. These families tend to eat poorly, forgo exercise, and skip medications to stretch their budget. Low incomes force many to live in unhealthy housing or in struggling or insecure neighborhoods. Such neighborhoods tend to have limited access to medical care, nutritious groceries, and safe places to exercise and an oversupply of fast foods, liquor stores, pollution, and crime. A life of hardships is associated with higher rates of stress and depression. The association between income and health applies to everyone, not just those who are poor. Middle-class individuals have lower life expectancy and worse health status than those who are wealthy. Rich or poor, individuals facing more difficult financial circumstances tend to defer clinical care and allow complications to linger. Disadvantaged patients present to physicians in more advanced stages of disease that are more difficult and costly to treat and are often less survivable. In sum, budget policies that impose financial strain on families or curtail educational opportunities could, in time, cause greater morbidity, mortality, and costs—all of which are problematic on moral and economic grounds. The moral issue is clear: it is unsettling to adopt policies that will induce a higher rate of premature deaths or greater disease or disability. Such policies tend to disproportionately affect those who are poor or who are members of racial or ethnic minority groups, and they often affect children as well. These policies would be soundly rejected if health outcomes and ethics were the only considerations, but policy makers must also contend with economic and political realities. The core argument of fiscal conservatives is that difficult budget decisions and fiscal discipline are necessary for the economy—a worthy principle for many spending areas. However, fiscal discipline loses its logic when spending reductions lead to greater illness and thereby increase health care costs. Any policy that increases disease burden is a threat to the economy because medical spending is so costly to government and employers. Medicare, Medicaid, and children’s health insurance consume 23% of the federal budget. Health care costs are complicating efforts to balance state budgets, operate businesses, and compete in the global marketplace. The need to control medical cost inflation is a mounting national priority, one that argues against budgetary policies that would increase morbidity, heighten demand on the system, and drive up medical spending.