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A National Security Case for Public Health Infrastructure and Universal Healthcare

A U.S. Army Corps of Engineers press briefing at the Pentagon.

I’ve been asked a lot for my view on American health care. Well, ‘it would be a good idea,’ to quote Gandhi.

Paul Farmer

National Security, Public Health, and Universal Healthcare Heading link

The intersection of public health and national security is often explored within the context of bioterrorism. SARS-CoV-2 disease 2019 (COVID-19) offers an opportunity for us to consider the national security implications of strengthening public health infrastructure and adopting a universal healthcare system. We must remember, a chain is only as strong as its weakest link. Current public health infrastructure failure and a near collapse of our costly, inefficient healthcare system, is no Black Swan. It was entirely predictable as public health professionals have been warning of such a scenario as a result of path dependency. Decisions to defund public health programs, such as the U.S. Agency for International Development (USAID)-funded global program to detect and discover viruses in animal hosts with pandemic potential, and bipartisan failure to create and sustain a federal, single-payer healthcare system that provides comprehensive coverage to everyone absent of costly insurance premiums, high deductibles and gaps in coverage, have led us to be woefully underprepared and lacking the capacity to respond to a significant global public health crisis.

The U.S. spends approximately $3.6 trillion or $11,172 per person each year on healthcare, accounting for roughly 18% of our Gross Domestic Product. The U.S. currently ranks highest in health care spending in the world. Comparatively, only $19 is spent per capita on foundational public health measures and programs, when only $32 per person is needed to meet foundational public health service needs. The U.S. spends more than $2000 per capita on its military budget. In fact, the most recent budget proposal requested more than $700 billion for national security. Both military and healthcare spending has continued to increase while public health spending has continued to decrease with an ill-informed, increasingly rare bipartisan consensus. Healthcare cost has been a known fiscal Armageddon for a while. This amount of spending is unsustainable, risks economic collapse, and puts U.S. national security at risk.

Although the intersection of public health and national security, especially domestically, is seldom examined within the public health community, there is a precedent of certain infectious diseases being declared national security issues. For instance, HIV/AIDS has been declared a national security threat. The U.S. National Intelligence Council has argued that infectious diseases are a threat to U.S. national security, stating infectious diseases will “endanger U.S. citizens at home and abroad, threaten U.S. armed forces deployed overseas, and exacerbate social and political instability in key countries and regions in which the United States has significant interests.” Public health emergency preparedness (PHEP) has been defined as “the capability of the public health and health care systems, communities, and individuals, to prevent, protect against, quickly respond to, and recover from health emergencies, particularly those whose scale, timing, or unpredictability threatens to overwhelm routine capabilities.” It is clear from the federal response to COVID-19 that PHEP, a critical aspect of protecting our nation’s security, has not been a priority for political decision-makers.

Military Readiness and National Security Threats Heading link

There are direct national security implications of poorly funded public health infrastructure and universal healthcare. While the overall health of U.S. citizens and our capacity to adequately and expeditiously respond to health threats is a critical national security issue, it puts our military at risk, even potentially limiting eligible recruits. Inadequate preparation and delayed responses, as reflected in the current response to COVID-19, puts additional strains on our public health systems, our military, and the frontline workforce. Inadequate response to this pandemic has necessitated the use of military personnel and equipment, due to significant nationwide public health infrastructure and resource deficits, resulting in severe illness and tens and thousands of preventable deaths. Additionally, a lack of sustained public health financing in the early phases of this pandemic placed U.S. civilians as well as military personnel at risk and may have adversely impacted military readiness. Although the military personnel are generally younger and healthier than the general population, the virus does not discriminate by service status or age. Moreover, healthy people are not immune to COVID-19, and can still become severely ill, require hospitalization, or die.

Pandemic Team…What Pandemic Team? Heading link

The current Administration has aggressively pursued public health defunding and deregulatory agendas, which include disbanding of the National Security Council Unit focusing on pandemic preparedness and slashing funds for the Centers for Disease Control and Prevention and the World Health Organization amidst the COVID-19 pandemic. The Tax Cuts and Jobs Act’s reallocation of funds from the Prevention and Public Health Fund (PPHF), $750 million immediately and $1.35 billion over the course of a decade, further strains public health initiatives, including outbreak responses and immunization efforts. These defunding trends are not unique to the current Administration. Defunding public health is a bipartisan practice with policymakers across the political spectrum regularly rolling back public health funding.

Koonin and Patel (2018)recount that during the 2009 H1N1 pandemic, just 40% of those ill sought medical care within three days of becoming ill, which is cause for concern considering the role of timely access to care in reducing mortality and morbidity. Seeking care in a timely manner can reduce morbidity and mortality as well as protect others from infection. It is not difficult to imagine that some 28 million uninsured people, as well as the 29% of those currently with insurance who are underinsured, would avoid seeking medical care due to related costs, such as high deductibles and copayments, which may lead to household debt and bankruptcies. A universal healthcare system is best equipped to address future pandemics and other national security threats, such as climate change. During pandemics, medication and dispensing supplies plus costs may vary, which can limit access to and availability of critical care. Christina Ho outlines Disaster Relief Medicaid (DRM), which is the precedent for expanding health care access in the midst of a crisis. Such Medicaid expansion efforts, with low administrative burdens, have been implemented in response to natural disasters, the H1N1 pandemic, and lead contamination. Ho further argues the current Administration’s inadequate response to COVID-19 and the push for block-grant Medicaid at this time undermines this precise feature of Medicaid: “the open-ended financing structure, that enables it to respond so quickly to unexpected health threats.” Furthermore, providing clinical care to those affected by COVID-19 while neglecting other life-threatening acute or chronic conditions is unethical and disproportionately impacting our most vulnerable communities.

Political Economy and Health Heading link

The historical roots of public health are inherently tied to politics and political economy. Ultimately, the public health community should ardently support policies that protect public health. Silence and inaction are stances that support the status quo. Furthermore, the status quo is not working. Our current inefficient, wasteful, and inequitable healthcare system is structured to provide the best healthcare that money can buy at the expense of the majority of the U.S. population, including essential workers, who have made invaluable contributions amidst the current pandemic, including but not limited to farm and agricultural workers, grocery store employees, healthcare workers, mail delivery workers, and so on. COVID-19 makes visible how the health of the most affluent and privileged is dependent on the health of the most marginalized and destitute. The backbone of the economy is constituted by people with diverse socio-economic backgrounds, such as race, gender, age, and citizenship status, the majority of which live paycheck to paycheck. Realities of this pandemic highlight the inadequacies and public health risks of the employer conditioned or provided healthcare. In the midst of a global health crisis, many underemployed and unemployed U.S. residents, which are currently exponentially increasing, lack access to adequate health insurance coverage.

Politicization of Evidence Heading link

The politicization of evidence-based healthcare systems, public health financing, and interventions is nothing new in the U.S. Empirical research cautions policymakers of the potentially detrimental effects of politicizing non-partisan health priorities, such as H1N1 or COVID-19. Current Administration’s policy priorities undermine our nation’s public health and include practices and programs that intensify social inequities. For instance, states that did not expand Medicaid now face higher rates of uninsured and underinsured people and hospital closings, which reduce access to care and skilled employment opportunities. Rural hospital closures have reached their highest peak this decade in 2019, and urban regions have also witnessed a dearth of hospitals, skilled healthcare workforces, and prescription drugs. A total of 47 hospitals closed in 2019 alone, according to the Medicare Payment Advisory Commission.

In public health crises such as with COVID-19, health care access and quality are critical components to achieving the triple aim of public health: improving the experience of care, improving the health of populations, and reducing per capita costs of health care. Inadequate public health preparedness, including substandard funding and infrastructure, increases our nation’s healthcare system’s vulnerabilities and exacerbates health inequities. Creating sustainable public health funding mechanisms and adopting a universal healthcare system may not only strengthen our nation’s health security but also help contain costs and prevent economic instability. The latest research and findings of the prominent libertarian think tank, the Koch Family Foundation funded Mercatus Center, support the fiscal viability of universal healthcare, with considerable savings associated with plan features and implementation.

Proactive Approach to Contemporary & Future Threats Heading link

Current COVID-19 responses, which cost trillions of dollars, are reactionary and highlight the structural issues associated with chronic cuts to public health budgets along with health care and safety net programs and the primacy of healthcare industry profiteering. This is all preventable. Ben Franklin suggests, “an ounce of prevention is worth a pound of cure.” This sentiment remains true in 2020. The Constitution prominently features economic and social rights but addresses them with little specificity. The Preamble states that an overriding purpose of the U.S. Constitution is to “promote the general welfare” of the citizenry, indicating that issues such as poverty, housing, food security, and other economic and social welfare issues were of central concern to the framers. Chronically defunded public health systems have not served us well during this recent pandemic or those of yesteryear. Sustainable, long-term funding for public health infrastructure, preventive services, and care as well as understanding and improving upon social, economic, and environmental factors that affect health, such as housing security, a livable wage, neighborhood safety, and high-quality education, is critical to a healthy and resilient society. A well-funded public health system and a universal healthcare system is an evidence-based, sound investment in the future of this country, which will strengthen our national security capacity by reducing the risk of a system collapse associated with potential pandemics.

COVID-19 will not be the last pandemic. Continued ecosystem degradation and climate change facilitate the spread of infectious diseases. Further, a U.S. Global Change Research Program workshop report highlights the need for a comprehensive framework, with public health at its core, to prepare for and respond to threats at the intersection of climate change, infectious disease, and national security. With climate change leading to weather pattern changes, rising temperatures and sea levels, food insecurity, and thawing permafrost, infectious diseases will continually pose a growing threat to human health. The Human Health chapter of the recent National Climate Assessment estimates that under a high emissions scenario, similar to the emissions pathway before the implementation of COVID-19 public health response policies, the health-related costs of West Nile neuroinvasive disease alone are projected to be approximately $1 billion per year by 2050 and an additional $3.3 billion annually by the end of this century (in 2015 dollars). Failing to prioritize the protection of public health and ensure adequate public health preparedness and response not only puts our nation at risk in the near term, but it also exacerbates the impacts of climate change and climate-sensitive infectious diseases in the future.

Final Thoughts Heading link

A well-funded equitable public health system will leave us better prepared, and independent of reactive public health measures that may be inadequate, inefficient, and unjust. Moreover, approximately two-thirds of the U.S. public supports some form of a federally funded healthcare system conducive to universal coverage. Decades of public health defunding, deregulation, privatization, mistrust of empirical evidence, and the proliferation of misinformation have led to our current anxiety-fueled state of affairs. Moreover, if the latest stock market tumbles and job losses are any indications, a universal healthcare system is imperative to ensure economic resilience, favorable mental and physical health outcomes, and an international competitive edge. The current healthcare system, including employer-based health insurance, is costly and inefficient. It burdens many with medical debt and denies a significant number of Americans access to high-quality health care and the right to pursue happiness as enshrined in our Declaration of Independence. Universal healthcare is a humane, patriotic priority, which is especially critical to our national security, from the health of our neighbors to the health of our soldiers and the resilience of our economy. Public health practitioners and researchers must cease this moment to highlight the most critical, but distinct from the healthcare systems, role of public health and aggressively advocate for it beyond just a social justice issue. We need to redraw our social contract and demand a paradigm shift from a primitive medicalized model of putting healthcare before public health. We must reckon with the fact that pouring billions into healthcare will not do us well if we do not invest in public health and universal healthcare as a component of a broader public health system. It is time to abandon the bipartisan special interest bidding in favor of supporting evidence-based public health systems financing and universal healthcare to achieve a Culture of Health. After all, what does national security mean if we are not protecting our citizens from harm?

About the authors Heading link

Ashley Bieniek-Tobasco, DrPH, is an assistant professor of environmental and occupational health sciences at the University of Illinois Chicago (UIC) School of Public Health.

Cynthia Golembeski, MPH, is a JD/PhD student in the School of Public Affairs and Administration and non-tenure track faculty member with the New Jersey Scholarship and Transformative Education in Prisons Consortium at Rutgers University–Newark.

Ans Irfan, MD, is a professorial lecturer at the George Washington University Milken Institute of Public Health.

This article was originally published in Medium.

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