Health debt is the accumulated impact of changes in health behaviors during the pandemic that will have long-term negative effects on health.
Health Affairs Blog
Liz Ruth; Jeanne Alongi and John Robitscher
SEPTEMBER 17, 2021
Key Messages:
What is the problem?
- By June 2020, an estimated 41 percent of US adults had delayed or avoided medical care (12 percent emergency care and 32 percent routine care).
Studies have shown significant decreases in cancer screenings, biopsies, surgery, and treatment during the pandemic. … early in the pandemic colon cancer screenings dropped 86 percent and breast and cervical cancer screening dropped 94 percent.
… LDL cholesterol and HbA1C testing dropped 81–90 percent, and new medication therapy to manage high cholesterol and high blood sugar fell by 52–60 percent.
… 11 percent (or 28 million) of adults have delayed getting dental care
- While those numbers have rebounded, they remain below pre-pandemic levels.
What is the impact of the pandemic?
- Americans have accumulated an enormous health debt over the past 14 months due to delayed or missed preventive screenings, delayed treatment of existing diseases, forgone chronic disease management activities, and changes in health behaviors that have a negative impact on health (for example, increased alcohol consumption and reduced physical activity).
- The changes in health behaviors caused by the pandemic could erode advancements made in chronic disease prevention and control including cancer prevention and smoking cessation.
- There has been a parallel impact on health behaviors related to coping with pandemic realities that are linked to increased risk of developing new chronic disease. … approximately 43 percent of Americans report having worse exercise habits compared to before the pandemic, 31 percent report worse diet habits, and 31 percent report that financial hardship has prevented them from seeking health care in the last quarter alone.
- Not only will there be substantial financial costs to meeting the increased health care need resulting from these behavioral changes, there will also be enormous human and social costs.
What is the challenge for states?
- State chronic disease directors are at the epicenter of this looming crisis.
- Historically underfunded, state health departments are now experiencing an even greater challenge due to the pandemic.
What are the recommendations?
- Urgent Action Is Needed: Stemming The Tide Of Health Debt
- Overall, strengthening chronic disease prevention and control activities will address health debt and prevent the continued epidemic of chronic disease.
There are several opportunities for meeting this crisis head on.
- Increase Funding To States To Prioritize Evidence-Based Chronic Disease Prevention
- Consistently Provide Federal Funding To Ensure Adequate Public Health Infrastructure And Workforce That Last Beyond The Pandemic
To adequately address the existing and future chronic disease needs, the NACDD recommends tripling the NCCDPHP’s budget to ensure that every state has the funding it needs to address chronic disease prevention and health promotion.
- Invest In Public Health Data Modernization/Improve Chronic Disease Surveillance
Conclusion
- Even as vaccination rates increase and COVID-19 cases go down, the impact of the health debt will continue to affect the health and well-being of Americans.
- Ignoring the health debt accumulated during the pandemic is a grave oversight that will prolong the aftershocks of changes in health behaviors.
As attention turns to the next pandemic, how can the United States and the rest of the world be better prepared?
- Any discussion about pandemic preparedness should include serious conversations about how to address any existing health debt to ensure a healthier population with fewer chronic diseases and better chronic disease management.
FULL VERSION
Health debt is the accumulated impact of changes in health behaviors during the pandemic that will have long-term negative effects on health.
Americans have accumulated an enormous health debt over the past 14 months due to
- delayed or missed preventive screenings,
- delayed treatment of existing diseases,
- forgone chronic disease management activities, and
- changes in health behaviors
that have a negative impact on health (for example, increased alcohol consumption and reduced physical activity).
The changes in health behaviors caused by the pandemic could erode advancements made in chronic disease prevention and control including cancer prevention and smoking cessation. Screenings such as mammograms and colonoscopies have significantly improved the early detection and treatment of cancers, allowing providers to catch cancers earlier and reduce the chance of mortality from them.
We also explore how doctors are now seeing much more advanced cases of disease that if they had been caught earlier could have been treated but are now fatal.
Health debt is the accumulated impact of changes in health behaviors during the pandemic that will have long-term negative effects on health.
While the full impact of COVID-19-related health debt will not be known for several years, these disruptions in health care and changes in health behaviors have a compounding effect on health outcomes.
One study of a six-month closure of a VA facility after Hurricane Sandy showed uncontrolled hypertension persisted for 24 months even after the facility reopened.
If the global pandemic was an earthquake, health status and health behavior surveillance are the siren warning of the impending health debt tsunami of increased chronic disease and the related morbidity and mortality that will deepen the health inequities that have been laid bare by COVID-19.
Below, we examine how the health debt came about. We discuss the critical role of state public health agencies in dealing with this issue and offer an agenda to address the current health debt and to prepare for the next pandemic and its consequences.
… health status and health behavior surveillance are the siren warning of the impending health debt tsunami of increased chronic disease and the related morbidity and mortality
What Contributed To The Health Debt?
The pandemic created significant challenges for people seeking medical care, including state policies requiring people to shelter in place, hospitals asking patients to delay non-urgent appointments, and clinical sites’ safety protocols limiting access to health care providers for several months.
Even as state and institutional restrictions were lifted, the fear of being exposed to COVID-19 kept many people from going to the doctor for preventive screenings or for the management of existing chronic diseases.
In addition, losing employer-sponsored health and dental insurance due to unemployment during the pandemic contributed to cost being an even more significant barrier for those who are uninsured or underinsured.
By June 2020, an estimated 41 percent of US adults had delayed or avoided medical care (12 percent emergency care and 32 percent routine care).
- Studies have shown significant decreases in cancer screenings, biopsies, surgery, and treatment during the pandemic.
- One study of 60 health care organizations covering 306 hospitals showed that early in the pandemic colon cancer screenings dropped 86 percent and
- breast and cervical cancer screening dropped 94 percent.
While those numbers have rebounded, they remain below pre-pandemic levels.
Beyond cancer screenings, a study of two large health care institutions revealed
- LDL cholesterol and HbA1C testing dropped 81–90 percent,
- and new medication therapy to manage high cholesterol and high blood sugar fell by 52–60 percent.
Again, the rates began to increase after the initial onset of the pandemic but not quickly enough to make up for the significant debt of missed screenings and disease management activities.
Dentists are also seeing the impact, with research showing that 11 percent (or 28 million) of adults have delayed getting dental care, which points to a growing number of people with untreated oral health issues.
There has been a parallel impact on health behaviors related to coping with pandemic realities that are linked to increased risk of developing new chronic disease.
According to the NACDD COVID Resilience Dashboard, a collaboration between the National Association of Chronic Disease Directors (NACDD) and Gallup, Inc.,
- approximately 43 percent of Americans report having worse exercise habits compared to before the pandemic,
- 31 percent report worse diet habits,
- and 31 percent report that financial hardship has prevented them from seeking health care in the last quarter alone.
Not only will there be substantial financial costs to meeting the increased health care need resulting from these behavioral changes, there will also be enormous human and social costs.
There has been a parallel impact on health behaviors related to coping with pandemic realities that are linked to increased risk of developing new chronic disease.
Critical Role Of State Public Health In Addressing Health Debt
State chronic disease directors are at the epicenter of this looming crisis. States have long played a pivotal role in preventing and detecting chronic diseases through evidence-based programs and policies.
State chronic disease directors and the state health departments where they work have a unique role in coordinating activity, steering resources to communities most in need, and creating linkages across systems with health care providers, insurers, educators, community organizations, and others.
State chronic disease programs facilitate partnerships with community-based organizations, local health departments, primary care physician groups, and federally qualified health centers.
They also communicate with vulnerable populations and integrate chronic disease messaging and resources to address nutrition, physical activity, food insecurity, and other underlying causes of chronic disease.
Chronic disease directors and their staff translate data for stakeholders, decision makers, partners, funders, and the public.
This knowledge is critical to understanding the existing burden of chronic disease in counties, cities, and states and to addressing ballooning rates of chronic disease due to the accumulated health debt.
Historically underfunded, state health departments are now experiencing an even greater challenge due to the pandemic. Public health funding saw significant cuts after the Great Recession, and funding levels have never recovered.
Although there have been significant supplemental funds provided by the federal government to address COVID-19, from 2008 to 2018 state spending on public health remained flat, and 38 states did not increase spending for chronic disease prevention.
Limited funding has meant many states are experiencing hiring freezes or losing full-time positions. In the NACDD Annual Survey of States fielded in November 2020, 90 percent of states reported that at least some of their chronic disease prevention staff were reassigned to COVID-19 response full or part time.
Forty-eight percent of chronic disease directors also reported that overall capacity to practice effective chronic disease prevention had decreased compared to the previous year due to COVID-19-related interruptions, with similar reported interruptions in effective partnerships with both private- and public-sector organizations and agencies.
Historically underfunded, state health departments are now experiencing an even greater challenge due to the pandemic.
Urgent Action Is Needed: Stemming The Tide Of Health Debt
Overall, strengthening chronic disease prevention and control activities will address health debt and prevent the continued epidemic of chronic disease.
There are several opportunities for meeting this crisis head on.
Increase Funding To States To Prioritize Evidence-Based Chronic Disease Prevention
Lack of physical activity, poor nutrition, tobacco use, and excessive alcohol use are responsible for many chronic diseases.
In fact, if these major risk factors were successfully addressed, at least 80 percent of all heart disease, stroke, and type 2 diabetes would be prevented, as would more than 40 percent of cancer cases.
The evidence is clear about what prevents chronic disease, but we are not prioritizing prevention.
- For example, in 2017–18, 42 percent of US adults were obese, but only 16 states received federal funding to support physical activity and healthy eating through state-based public health programs.
Consistently Provide Federal Funding To Ensure Adequate Public Health Infrastructure And Workforce That Last Beyond The Pandemic
Over the past decade, the Centers for Disease Control and Prevention’s (CDC’s) overall budget has fallen by 2 percent after adjusting for inflation.
In July 2021, the House Appropriations Committee approved the fiscal year (FY) 2022 Labor, Health and Human Services, Education, and Related Agencies funding bill that includes a total of $10.6 billion in funding for the CDC, an increase of $2.7 billion above the FY 2021 enacted level and $1 billion above President Joe Biden’s budget request. While an overall CDC budget increase is critical for providing adequate investment in public health, the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) would receive an increase of only $280 million.
To adequately address the existing and future chronic disease needs, the NACDD recommends tripling the NCCDPHP’s budget to ensure that every state has the funding it needs to address chronic disease prevention and health promotion.
… the NACDD recommends tripling the … budget to ensure that every state has the funding it needs to address chronic disease prevention and health promotion.
Invest In Public Health Data Modernization/Improve Chronic Disease Surveillance
Public health data modernization continues to be a priority at the federal and state levels as an important way to improve the tracking of chronic diseases, risk factors, and social determinants of health.
Data modernization is often talked about as if there is only one solution, but to effectively address the public health need will likely require multiple solutions.
- One option is to explore how to leverage work done by states during the pandemic to collect data and create dashboards to track testing, cases, and hospitalizations in real time, and to apply this work to other public health issues. These dashboards can improve the digital public health infrastructure and help address chronic disease.
- Other important data modernization methods include electronic health record (EHR)-based surveillance, including Multi-state EHR-based Network for Disease Surveillance (MENDS), as well as
- surveys and panels like those used by Gallup.
Data modernization is often talked about as if there is only one solution, but to effectively address the public health need will likely require multiple solutions.
Even as vaccination rates increase and COVID-19 cases go down, the impact of the health debt will continue to affect the health and well-being of Americans.
Ignoring the health debt accumulated during the pandemic is a grave oversight that will prolong the aftershocks of changes in health behaviors.
As attention turns to the next pandemic, how can the United States and the rest of the world be better prepared?
Any discussion about pandemic preparedness should include serious conversations about how to address any existing health debt to ensure a healthier population with fewer chronic diseases and better chronic disease management.
Any discussion about pandemic preparedness should include serious conversations about how to address any existing health debt to ensure a healthier population with fewer chronic diseases and better chronic disease management.
Originally published at:
TAGS: Resilient Health Systems; Post Pandemic Management; Budget;
