Ethical Considerations - Achiever Papers

Christian values are in the news frequently. Describe an example within the past year that includes an issue or environment related to health care. Locate an electronic media article and explain how the story frames the ethical considerations of the topic, addressing whether the position is fairly or equally provided by the media source. Determine whether you are able to identify the journalistic preference in the outcome. You must provide the link to the electronic media article.

May/June 2019 | Volume 37 Number 3140

Nursing Economic$

Twitter has opened up a world of possibility to build a network of
colleagues across sectors. After
the shooting at my niece’s
school in Parkland, FL, I
became much more outspoken
on social media about the issue
of gun violence as a public
health crisis (Cogan, 2018). In
my social media activism, I
connected with a group of
physicians who were also
speaking out about gun
violence prevention.

The power of social media
connected me to the work of
AFFIRM Research and Dr.

Megan Ranney

. Through months
of tweeting and sharing
resources, a relationship was
forged that somehow broke
through the anonymity of the
Internet and created a
professional and also a personal
connection. I am a school nurse
being welcomed into a
physician-driven organization. It
has been a career privilege to
work side by side with some of
the leaders of the movement to
address gun violence as a public
health crisis. In early February
2019, I attended an in-person
meeting with AFFIRM and those
organizations that support the

urgency of funding firearm
violence prevention. I was the
only nurse. This must change.

Through my advocacy work,
I reached out to several national
nursing organizations, expressing
the importance of supporting the
work of AFFIRM Research and
asking for public support. My
disappointment at the lack of
response rivals my elation at
being offered a seat at this table.
But I do not want to be the lone
nurse in this work. Where are
the national nursing
organizations? Where do they
stand on the issue of gun
violence as a public health crisis?

Nurses are in a unique time
of transformation and
interdisciplinary collaboration to
solve some of our biggest public
health challenges. Let’s not miss
the opportunity to work with
physicians, scientists, public
health professionals, and
researchers. This is our moment
to join in collaborative efforts to
face the most urgent needs of
our community and proactively
address the “wicked problems”
that impact our world. We need
to answer the call with a
resounding yes! We are in a
public health crisis and who
better than nurses, steeped in

Creating Partnerships that Reflect
the Collective Will of Healthcare
Professionals: An Interview with
Megan Ranney
Robin Cogan

The gun violence epidemic
continues to trend upward in the
United States with scant
research on injury protection and
prevention. In this interview,
Megan Ranney, emergency
room physician and co-founder
of the American Foundation for
Firearm Injury Reduction in
Medicine, discusses the
challenges and opportunities for
firearm injury research, and the
critical role nurses can play in
achieving solutions.

Megan Ranney

May/June 2019 | Volume 37 Number 3 141

evidence-based practice, to help
solve the epidemic of gun
violence.

Megan Ranney, MD, MPH,
FACEP, is Associate Professor,
Department of Emergency
Medicine, Rhode Island
Hospital/Alpert Medical School
of Brown University; Director
and Founder of the Brown
Emergency Digital Health
Innovation Program; and
Director of Special Projects,
Department of Emergency
Medicine. Dr. Ranney’s career
focus is on developing, testing,
and disseminating digital health
interventions to prevent violence
and mental illness. She is
currently principal investigator or
co-investigator on six federally
funded grants and has over 100
peer-reviewed publications. She
holds numerous national
positions, including serving as
an elected member of the Board
of Directors of the Society for
Academic Emergency Medicine,
Chair of her Governor’s Task
Force for Gun Safety, and as an
editor for Annals of Emergency
Medicine. She is also Chief
Research Officer and Co-founder
of AFFIRM (American
Foundation for Firearm Injury
Reduction in Medicine), a non-
partisan non-profit organization
committed to funding and
disseminating firearm injury
prevention research. She also
leads courses for undergraduates
and medical students at Brown
University. She has received
numerous awards for technology
innovation, public health, and
research. She is active on Twitter
@meganranney.

In this Nursing Economic$
interview, Dr. Ranney shares her

personal and professional
reflections about creating
partnerships that truly reflect the
collective will of healthcare
professionals. Nurses, are we
ready to join the call to action?

Changing the Curve on
Injury Epidemics

Robin Cogan (RC): What is
the overarching goal and
mission of AFFIRM?

Megan Ranney (MR):
AFFIRM is a non-partisan, non-
profit organization created in the
face of continued federal
inaction on firearm injury
prevention funding. Founded by
myself and Dr. Chris Barsotti
(AFFIRM Chief Executive
Officer), we are made up of a
Research Council (containing
many of the nation’s leading
violence prevention researchers),
an Advisory Board (with Robin
on it!), and, as of March 2019,
the partnership of over 17
healthcare organizations.
AFFIRM’s mission is to end the
epidemic of gun violence
through research, innovation,
and evidence-based practice.

As you know, there has
been limited funding for firearm
injury research for the past 22
years. In 1996, a junior
representative from Arkansas,
Jay Dickey, put a rider on a bill
– the now infamous “Dickey
Amendment” – that resulted in
moving all the money out of the
Centers for Disease Control and
Prevention (CDC) that had been
previously spent on firearm
injury prevention research. Since
1996, the CDC has had $0 in
appropriations for firearm injury
prevention research; the

National Institutes of Health
have spent less than 2% of what
would be predicted based on
the number of people who die
from firearm injury each year.
And as a result, the state of the
science for gun violence
prevention is pretty much where
it was in 1996, when the Dickey
Amendment was passed. Yet
society, and patterns of injury,
have changed tremendously –
and both the number and rate
of firearm injury and death have
increased substantially. Our goal
at AFFIRM is to mobilize
Americans across the country to
create solutions and hope,
together. We don’t need to wait
on someone else to make a
difference; this is a solution that
we can all invest in.

Some examples of
immediate actions include:
• Educating.
• Helping people to share

stories, through blogs,
infographics, and a new
podcast.

• Sharing research results and
reasons why more research
is needed.

• Developing research awards
that people can apply to.

• Providing donation
opportunities, to allow
average Americans to make a
difference.

• Launching a series of
AFFIRM Across America
events in the fall.
RC: What drives your

personal and professional sense
of urgency about gun violence
prevention research?

MR: I am driven by my
clinical work: I am an
emergency physician and take
care of victims of gun violence

Nursing Economic$

May/June 2019 | Volume 37 Number 3142

far too often. I see both the
immediate impact on the body,
and its long-term physical and
mental effects. And I see the
effects on families, communities,
and healthcare providers: PTSD,
substance use, burnout.

I am driven by my research:
I am a fellowship-trained injury
prevention researcher. I know
that we have successfully
changed the curve on injury
epidemics in the past. I know
that we can do the same for
gun violence.

I am driven by my personal
life. I am a mom of two, and
fear for my kids’ future. Like so
many of us, I’m also a friend or
family member of those who
have been directly affected by
gun violence.

Finally, I am driven by the
silence. Up until this year,
healthcare professionals were
largely silent about the effect of
firearms on Americans’ health –
and about the moral and
scientific imperative to stop this
epidemic. Federal funding for
firearm injury research remains
abysmally low. I, along with
many others, am proud to help
lead the movement toward
change, by raising and
distributing money within
AFFIRM.

Creating Partnerships in
Health Care

RC: What would a
partnership with nursing look
like? Why is it important to
collaborate with nurses?

MR: My grandmother and
my aunt are nurses, and their
combination of emotional
intelligence and intellectual rigor

influenced my decision to go
into health care. Every day, in
the emergency department, I am
reminded that the quality of
health care is only as good as
the quality of the nurses I work
with. So, it would be crazy to
think that we’ll solve an
epidemic like gun violence
without nursing being part of it.
Your voice, what you see, your
perception of the issue and of
possible solutions, and your
research skillset, are a critical
part of the solution. My goal is a
full partnership – sometimes
you lead, sometimes I lead,
sometimes we just put our
heads down and work together.

RC: AFFIRM is intentional
about working cross-sector and
including voices from multiple
disciplines. You spoke about the
“collective will of healthcare
professionals.” What steps have
you taken to create partnerships
that reflect this collective?

MR: At AFFIRM, we know
that solving a societal issue of
this magnitude takes literally all
of us. Research is the first step –
but it can’t stop there. We also
need to implement change
based on this research. To
effectively create change, we
need representatives from every
part of health care in the room.
Together, we can design, study,
and then push out protocols
that better care for those who
are left behind after a shooting;
and, better yet, protocols that
can identify patients at risk and
help stop shooters before they
shoot. This is why we have put
such an emphasis on creating
partnerships with healthcare
professional organizations: we
need to have all of us at the

table. (I would love to have
more nursing organizations as
partners – please feel free to
reach out to me if you’d be
interested in joining us.)

Prioritizing Research

RC: Given the decades of
limited research on gun violence
prevention, how do you begin
to set a priority agenda for
funding this research?

MR: The research agenda is
already large – there’s the 2013
Institute of Medicine (now
National Academy of Medicine
[NAM]) agenda; there’s the 2016
American College of Emergency
Physicians agenda; there’s the
agenda created by Kaiser after
the 2018 conference that they
held at NAM. The questions in
all these agendas remain to be
answered. The question of how
to prioritize is a tough one.

At AFFIRM, we feel the
priority needs to be on, first,
developing and disseminating
great interventions to prevent
injury among the highest-risk
patients. And, second, on
moving the needle: creating
innovative new ways to create
change. For instance, our
Research Council members are
creating predictive scores for risk
of shooting, apps to help suicidal
patients make decisions about
safer storage of guns, and social
media programs to measure
anxiety after a school shooting.

Other groups may have
different priorities, and that’s
okay. It takes all of us.

An Apolitical Stance

RC: Why is it important to

Nursing Economic$

May/June 2019 | Volume 37 Number 3 143

maintain an apolitical stance in
AFFIRM?

MR: For 2 decades, firearm
injury prevention research has
been labeled as inherently
political. As recently as March
2019, in a hearing before
Congress, some people asserted
that firearm injury research is
inherently biased. Let me be
clear: Nothing could be further
from the truth. Firearm injury
researchers don’t think guns are
“bad” any more than we think
cars are “bad.” Instead, we want
to find ways to identify who is
high risk (just as we know, for
instance, that drinking and
driving is inadvisable) and to
help them stay safe (just as for
cars, we changed the
windshields and the steering
wheels to reduce the risk of
injury). There’s no value
judgment. There’s just a desire
to mitigate injury.

To do this well, we need
Americans (and, more
specifically, healthcare
professionals and researchers)
from across the political
spectrum. When we make it
political, we leave out some of
the most important voices – and
we doom the potential for
creating real change.

RC: A Tweet shared more
than a year ago, continues to
reverberate on social media.
Please share the back story of
how you decided to ask this
question and what the answers
meant for your work as a
researcher/scientist studying
firearm violence prevention?
Here is a link to the Twitter
thread where readers can view
the stories that were shared as a
result of this one Tweet:

https://twitter.com/meganranney/
status/968324464713887746

MR: After each mass
shooting since Sandy Hook, I
and many others have called for
change. After Parkland, I and
many others were looking for
something concrete to do. One
thing that we, as doctors and
other healthcare professionals,
can do – in the absence of
research, in the absence of
funding – is to share our stories,
and (in a HIPAA-compliant
manner!) the stories of our
patients and our communities.
The average American doesn’t
understand what it means when
I say, “more than 100 Americans
die each day from firearm
injury.” And the average
American mostly thinks about
mass shootings when they think
about gun violence. This thread
was a first step in helping to
humanize the victims and those
they leave behind. The
responses – the daily tragedies
experienced by Americans
across this country – are what
motivate me, every day, to keep
doing this work.

A Public Health Effort

RC: The enormity of the
public health epidemic of gun
violence must not be a deterrent
in working collaboratively to
make our communities safer.
There is a saying in public
health that you can’t boil the
ocean, but we can each boil our
part of the ocean. Supporting
the work of organizations like
AFFIRM is one step nurses can
take to provide the public
support that is needed to fund
firearm violence prevention

research. Individual nurses can
reach out to their national
organizations and ask them to
publicly support AFFIRM and its
research. To date, only two
national nursing organizations
are in discussions with AFFIRM;
none are official partners.

Some of the feedback that I
have received when asking
national nursing organization
leaders to take a public stand is
that they are choosing to focus
primarily on nursing-related
issues. Another message was that
they have to be cognizant of the
entirety of their constituency and
that gun violence is a political
issue. The proverbial table is set
for a national presence of nurses
to join in the public health effort
of addressing gun violence pre –
vention, your seats are waiting. $

Robin Cogan, MEd, RN, NCSN
School Nurse
Camden City School District
Camden, NJ
Adjunct Faculty
Rutgers School of Nursing – Camden
Camden, NJ

Notes: For more information, please visit:
https://affirmresearch.org

The National Academies of Sciences,
Engineering, and Medicine convened a
workshop to examine the roles that health
systems can play in addressing the epidemic
of firearm injury and death in the United
States. To read the proceedings and explore
a digital overview of the workshop, please visit
nationalacademies.org/PreventFirearmDeath

Rep. Robin L. Kelly (D-IL) introduced H.R.
1114 – To require the Surgeon General of the
Public Health Service to submit to Congress
an annual report on the effects of gun
violence on public health. The proposal has
48 co-sponsors.

Reference
Cogan, R. (2018). Why I became a school

nurse activist. Nursing Economic$,
36(2), 57-58.

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Introduction

The Economics of Public Health:
Missing Pieces to the Puzzle of Health
SystemReform
Glen P. Mays , Adam J. Atherly ,and AlanM. Zaslavsky

The United States continues to experiment with health care delivery and financing
innovations, but relatively little attention is given to the public health system and its
capacity for improving health status in the U.S. population at large. The public health
system operates as a multisector enterprise in which government agencies work in con-
junction with private and voluntary organizations to identify health risks in the popula-
tion and to mobilize community-wide actions that prevent and contain these risks. The
Affordable Care Act and related health reform initiatives are generating new interest in
the question of how best to expand and integrate public health approaches into the lar-
ger U.S. health system. The research articles featured in this issue of Health Services
Research cluster around two broad topics: how public health agencies can deliver ser-
vices efficiently and how public health agencies can interact productively with other
elements of the health system. The results suggest promising avenues for aligningmedi-
cal care and public health practices.
Key Words. Public health services, health economics, health system reform

The American pursuit of health system reform seeks to close the yawning gap
between the resources consumed by our health system and the health out-
comes experienced in the U.S. population. The fact that the United States
ranks first among high-income countries in health spending per capita but
near the bottom in life expectancy, infant mortality, and other measures of
population health and health equity is now widely understood as a public
health problem and economic burden in need of remedy. The Affordable
Care Act (ACA) and related federal and state reform initiatives have focused
attention and resources on expanding health insurance coverage and, to a

©Health Research and Educational Trust
DOI: 10.1111/1475-6773.12782
PUBLIC HEALTH SERVICESAND ECONOMICS

2275

Health Services Research

http://orcid.org/0000-0002-7837-6812

http://orcid.org/0000-0001-6443-0761

http://orcid.org/0000-0003-1072-6043

lesser extent, improving the delivery of high-value medical care. Recent
research indicates that these reforms are achieving some of their most impor-
tant intended effects on coverage and care (Courtemanche et al. 2017; Dug-
gan, Goda, and Jackson 2017; Sommers et al. 2017). Much less policy and
scientific attention, however, focuses explicitly on the larger health reform
objective of improving health outcomes in the U.S. population at large.

HEALTH REFORMAND POPULATION HEALTH

Over time, some population-wide improvements in health status are likely to
accrue from successful efforts to expand health insurance coverage and extend
high-value medical care delivery to larger shares of the U.S. population (Som-
mers, Gwande, and Baicker 2017). Accountable care organizations, patient-
centered medical homes, care transition initiatives, and value-based payment
arrangements for medical providers are all ACA-supported strategies that
have the potential to improve health outcomes for patients, and some may
simultaneously help to constrain costs (Rajkumar, Press, and Conway 2015).
These strategies by themselves, however, are unlikely to intervene strongly on
social, economic, and environmental conditions, along with health behaviors,
that collectively exert powerful influences on health status and health dispari-
ties in the U.S. population. Similarly, current health reform strategies may
have limited ability to address these health determinants far enough upstream
in order to prevent disease and injury before they occur.

Fortunately, the ACA includes significant but less visible policy and pro-
gram components designed to strengthen the nation’s public health system—
the constellation of organizations that focus on reducing disease and injury
risks in the U.S. population at large. The most prominent of these components
include (1) creation of the Public Health and Prevention Fund that expands
federal funding for public health programs and infrastructure, and (2) imple-
mentation of new requirements for nonprofit hospitals to assess health needs
in the communities they serve and to develop plans for addressing these needs

Address correspondence to Glen P. Mays, Ph.D., M.P.H., Department of Health Management
and Policy, College of Public Health, University of Kentucky, Lexington, KY, and Center for
Health Services Research, University of Kentucky, 111 Washington Avenue #201b, Lexington,
KY 40536; e-mail: glen.mays@uky.edu. Adam J. Atherly, Ph.D., M.A., is with the Department of
Health Systems, Management and Policy, School of Public Health, University of Colorado-
Denver, Aurora, CO. Alan M. Zaslavsky, Ph.D., is with the Department of Health Care Policy,
HarvardMedical School, Boston,MA.

2276 HSR: Health Services Research 52:6, Part II (December 2017)

through community benefit activities that hospitals undertake as a condition
of their federal tax-exempt status (Rosenbaum 2011). The ACA also creates
new incentives for health insurers and employers to invest in health promo-
tion and wellness programs for their covered populations. In addition, the
transition to value-based health care payment arrangements under ACA and
related federal and state reforms may create stronger incentives for medical
providers to implement public health approaches for their patient populations
and to partner with others in supporting community-wide public health initiatives.

These nonmedical components of health reform offer important oppor-
tunities for research and learning about the implementation and impact of
public health strategies and for investigating how ACA’s medical and public
health components interact in shaping health systems and health outcomes.
Historically, the health services research field has focused relatively little
attention on the organization, financing, and delivery of public health pro-
grams and their impact on health outcomes. Kerr White, a founding father of
health services research in the United States, famously eschewed research on
public health practice in favor of the study of medical practice for its more
clearly defined purposes, providers, and processes (Berkowitz 2003). Until
recently, the demand for research focused on the public health system has
been driven principally by health professionals working in local, state, and
federal public health agencies, who represent a small niche within the vast col-
lection of U.S. health system stakeholders. After all, governmental public
health expenditures constitute <3 percent of national health spending in the United States (Martin, Hartman, and Washington 2017). Health reform and the ACA have begun to stimulate new demand for this type of research as hos- pitals, health systems, insurers, ACOs, and other stakeholders contemplate new ways of engaging with the public health system (McClellan 2014). Many health care organizations recently have created divisions focused on popula- tion health, and the market for consultants, educational offerings, and training programs devoted to population health continues to expand. The evidence base on how best to expand and integrate public health approaches into the larger U.S. health system, however, remains surprisingly thin.

UNDERSTANDING PUBLIC HEALTH AS AMULTISECTOR
ENTERPRISE

Like the medical care system, the public health system consists of a heteroge-
neous set of actors facing a mix of different incentives and constraints on their

The Economics of Public Health 2277

actions while pursuing a shared aim of improving health status (Mays et al.
2010). One class of public health actions involves the direct delivery of health
services to individuals, which is familiar territory for health services research-
ers who study medical practice. However, the personal health services deliv-
ered through the public health system tend to be those that (1) entail
significant spillover effects (externalities) on the health risks of entire popula-
tions of people, such as vaccinations and treatments for communicable dis-
eases, and (2) are incompletely delivered to the population at large through
the mainstream medical care system. A second class of public health actions
involves the implementation of policies, laws, and regulations designed to
shape the health-related behaviors and risks of large populations of people
and organizations, as in the typical subjects of health policy research. These
actions commonly focus on reducing environmental health risks in food,
water, air, soil, and the built environment.

A third class of public health interventions—perhaps the least under-
stood—focuses on stimulating and supporting collective action in society to
improve health and reduce risks. These actions aim to make organizations
from different sectors in the community more aware of health issues that they
might affect and to enlist their cooperation in pursuing solutions to these
issues. Public health agencies collect and analyze data on health needs and
risks within their communities, educate the public and community leaders
about community health needs and potential remedies, convene community
stakeholders to develop shared priorities and plans for addressing health
needs, advocate for needed health policy solutions, and recruit community
resources to support the implementation of health programs and policies.
These actions often target social, economic, and environmental determinants
of health that require engagement from nonhealth sectors such as housing,
education, transportation, social services, and business. This approach is
attracting increased attention in health policy and medical care practice as evi-
dence emerges about how unmet social and economic needs influence medi-
cal care utilization and outcomes (Alley et al. 2016).

Much of the responsibility for initiating and coordinating public health
actions falls to agencies of government—particularly state and local govern-
ment—working in partnership with an array of community organizations,
including medical care providers. The division of labor between local and
state agencies varies widely across the United States as do the roles played by
the private sector. The combinations of health programs and policies imple-
mented by public health agencies also vary widely across the United States,
driven by policy priorities of state and local elected officials and their

2278 HSR: Health Services Research 52:6, Part II (December 2017)

constituents, fiscal capacities of state and local governments, and the interest
of the private and philanthropic sectors in contributing to these activities.
The federal government plays a much more limited role in financing activities
within the public health system than it does for medical care. These structural
and fiscal realities of the public health system result in wide geographical vari-
ation in the practice of public health—another familiar circumstance for
health services researchers.

RESEARCH ON THE ECONOMICS OF PUBLIC HEALTH
PRACTICE

The challenge this poses to health services researchers is to adapt the theories
and methods honed in the study of medical practice in order to uncover the
causes and consequences of variation in public health practice. Such research
promises to point the way toward solutions that improve population health by
reducing harmful, wasteful, and inequitable variations, and by scaling up ben-
eficial innovations. Doing so can provide critical missing pieces to the puzzle
of U.S. health system reform.

Building this type of evidence requires answering some fundamental
questions about the economics of the public health system, such as the
following:

• What factors determine the mix of public health actions that are implemented in a com-
munity and the concordance of these actions with available scientific knowledge and
evidence-based guidelines?

• What resources are required to implement beneficial public health practices, and how
do resource requirements vary based on community needs and risks (IOM 2012)?

• What types of organizations and professionals are needed to implement beneficial prac-
tices, and what incentives and constraints do they face in engaging productively in this
work?

• How do public health practices influence demand for and utilization of medical care
and other social services?

• What financing mechanisms and regional delivery models are most effective and effi-
cient for supporting beneficial public health practices, and how do they vary across state
and community contexts in the United States?

• What decision tools and processes help communities to optimize their mix of public
health practices, consistent with available resources and the distribution of health needs
and risks in the community?

The Robert Wood Johnson Foundation (RWJF) has supported research
on these issues through a series of related programs implemented over more
than a decade. The Public Health Practice-based ResearchNetworks Program,

The Economics of Public Health 2279

launched in 2007, and the Public Health Services and Systems Research Pro-
gram, launched shortly thereafter, have fostered the development of influen-
tial early studies on these topics, while also helping to refine data sources,
methods, and research-practice collaborations required for successful lines of
inquiry (Mays and Scutchfield 2015). In 2016, these programs combined to
form supporting pillars for a new Systems for Action Research Program,
launched as part of RWJF’s efforts to increase scientific knowledge on building
a culture of health across the United States (Lavizzo-Morey 2017). Systems for
Action expands the scope of scientific research on these topics by focusing
attention on how medical, public health, and social services delivery systems
interact, or fail to do so, in supporting health improvements across the United
States (Mays et al. 2016).

NEWCONTRIBUTIONS AND NEWDIRECTIONS FOR
RESEARCH

The research articles featured in this issue of Health Services Research constitute
proofs of concept for the feasibility and utility of applying the methods and
tools of health services research and health economics to the study of public
health systems. The articles in this special issue cluster around two broad
topics: how public health agencies can deliver services efficiently and how the
public health system interacts with other pieces of the health care delivery
system.

The first four articles look at questions of short-run economic efficiency
and cost in different services: environmental health inspections (Cohen and
Checko), delivery of immunizations (Basurto-Davila et al.), and sexually trans-
mitted disease (STD) partner services ( Johnson et al.), and communicable dis-
ease surveillance (Atherly et al.).

Cohen and Checko used a longitudinal dataset to examine the possibil-
ity of economies of scale and scope in environmental health inspections in
Connecticut. The authors find that there are substantial economies of scale
and scope in the delivery of services. In particular, full-time municipal health
departments and regional health districts are closer to minimum efficient scale
than part-time health departments, suggesting that costs could be reduced if
smaller agencies were combined. Further, four different types of inspections
(water and septic, food and septic, food and lead, and lead and septic) have
economies of scope, suggesting total costs are reduced when the inspections
are performed together.

2280 HSR: Health Services Research 52:6, Part II (December 2017)

Basurto-Davila et al. investigated the economic gain frommore efficient
distribution of vaccinations through Maine’s school-based influenza vaccina-
tion (SIV) program. Using a difference-in-difference-in-differences analysis,
coupled with a Markov microsimulation model, the authors found that the
SIV program in Maine increased immunization among children—the target
population—and lowered immunization among adults aged 18–49 years and
65 and older. On net, the more efficient targeting of immunizations was esti-
mated to have prevented 4,600 influenza infections and generated $4.9 mil-
lion in net economic benefits.

Johnson et al. examined the cost of STD partner services for HIV,
syphilis, gonorrhea, and chlamydial infections. Delivery of partner services
varied across reported disease, ranging from 96 percent for HIV cases to 17
percent for chlamydia cases. Similarly, the cost per case varied by disease
type, from a high of more than $20,000 for HIV to a low of $1,700 for syphilis.
Yet more than half of the budget for partner services was devoted to chlamy-
dial infections. This highlights the need to understand costs of services to effec-
tively prioritize public health spending.

On the question of public health interactions with the broader medical
care system, the article by Mays examined how local expenditures for public
health activities influence area-level medical spending for Medicare beneficia-
ries. Using national data on public health and Medicare expenditures in local
communities over a 20-year period, the study found that adjusted Medicare
expenditures per beneficiary fell by 0.8–1.1 percent for each 10 percent
increase in public health spending per capita. The results suggest that public
health agencies could become helpful partners to medical providers partici-
pating in Medicare’s value-based payment models and accountable health
community initiatives.

Finally, Singh and Young look at the funding question through a dif-
ferent lens: partnerships between public health agencies and hospitals.
Hospitals are required under the Affordable Care Act to spend more on
community benefits and to develop community health assessments. Given
these requirements, partnerships with public health agencies would seem to
be a natural fit. However, Singh and Young find no relationship between
public health spending and spending on community benefits by hospitals.
Further, there was little relationship between measures of community need
(broadly defined) and spending by hospitals. The potential remains for a
partnership between hospitals and public health agencies, but it is just that
—a potential.

The Economics of Public Health 2281

CONCLUSIONS

These studies add substantively to our understanding of costs and resource
use within public health systems, the availability and quality of practices sup-
ported by these systems, and the impact of these systems on important health
and economic outcomes. Several of the articles included in this issue derive
from RWJF’s pioneering research programs devoted to these topics. We hope
the work profiled in this issue will collectively help to expand awareness of
and interest in these topics in both the research and health policy communi-
ties, leading to important new avenues of inquiry and continued experimenta-
tion with innovations in public health policy and practice.

Public health proved its value during the 20th century by producing as
many as 25 of the 30 additional years of life gained by the average American
(Bunker, Frazier, and Mosteller 1994). The long-term success of 21st-century
health reform initiatives may depend in part on our ability to harness the
power of modern public health strategies to produce better health at lower cost
for the U.S. population as a whole.

ACKNOWLEDGMENTS

Joint Acknowledgment/Disclosure Statement: Support for this issue was provided
by the Robert Wood Johnson Foundation for the Systems for Action
research program (grants 61471, 74715). The guest editors acknowledge
inspiration for this issue from the work of Linda Bilheimer, Ph.D., who
passed away in 2016. Dr. Bilheimer spent her career studying economic
issues in public health at institutions that included the Congressional Budget
Office, the Centers for Disease Control and Prevention, the Robert Wood
Johnson Foundation, Mathematica Policy Research, and the Arkansas
Department of Health.

Disclosure: None.
Disclaimer: None.

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SUPPORTING INFORMATION

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information tab for this article:

Appendix SA1: AuthorMatrix.

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