Prevention programs save lives and money — yet the budget process may undervalue them

Preventive health programs generally enjoy widespread and bipartisan political support. A review of Congress.gov indicates that legislation to strengthen disease prevention and health promotion made up almost a third of all proposed health-related bills in the last Congress. Yet funding for such efforts continues to fall short of what experts recommend.

We believe that certain structures in the budget process itself, while understandable in their intent, create barriers to legislation in this essential arena. With some small revisions, the true worth of an ounce of prevention could be a better guide to policymaking. Last month, the House unanimously passed the Preventive Health Savings Act, which would take a valuable step in improving the process. The Senate should do the same.

Clearly, prevention is preferable to avoidable illness, delayed diagnosis or expensive treatment. For decades, public health advocates have urged that this view be incorporated into federal financing. As health care costs rise and chronic illness and disability account for ever-larger shares of national health spending, the need has become increasingly pressing.

There is no obvious barrier to health promotion progress, given that there is broad academic and policy agreement on the widespread need and no opposition from insurers or health care providers. Rather, the obstacles reflect, at least in part, the way in which the Congress calculates spending and revenue, based on the cost estimates that the Congressional Budget Office (CBO) is required to make. While formal estimation techniques, known as “scorekeeping,” and time-limited budget frameworks are certainly necessary, they can have unintended consequences.

Preventive health activities are often good long-term investments with upfront costs. For instance, removing lead from drinking water and paint in older housing will eventually save billions of dollars in disability costs, but most of these savings show up long after the ten-year time period that guides congressional budgeting. Likewise, screening and intervention for such chronic conditions as obesity and diabetes can produce savings over time but may appear to be expensive when they are first undertaken. The costs of prevention programs may be relatively easy to estimate but the effects are notoriously hard to measure in either the short- or long-run.

To consider opportunities to elevate prevention in the federal budget, in 2022 we co-chaired a panel of former senior officials of the CBO and the federal Office of Management and Budget (OMB), under the auspices of the Health, Medicine & Society Program of the Aspen Institute. The panel included Democrats and Republicans with wide-ranging views on revenue and spending issues. The report, “Budgeting for Disease Prevention and Health Promotion: Improving the Federal Scorekeeping Process,” reflects the group’s consensus that significant improvements can be made in scorekeeping to help the Congress recognize the value of preventive health and to budget accordingly.

One recommendation is to provide more information about the context of costs and savings. Congress should know if preventive health legislation will have long-term effects, even if those are difficult to estimate and not included in the short-term construction of budgets.  While it may be problematic to develop specific estimates for outcomes further off in time, it may be possible to answer the basic question of whether or not there will be costs or savings. Such supplementary information would highlight the limits of official scorekeeping in such legislation and put the estimated cost of federal preventive health efforts in the context of long-term and widespread value for the nation. 

This is exactly what the House-passed bill would do. 

Our panel made other recommendations about improving scorekeeping for prevention. We suggest greater transparency about the analyses that inform CBO’s final price tag. We also recommend that scorekeeping include, to the extent possible, the distribution of costs and savings among population groups and among non-federal stakeholders, such as insurance plans and employers. Some of these recommendations could be undertaken by the CBO and the Budget committees themselves, and we hope that they will consider them in the future. Others, such as the need for additional funding for the CBO and for additional authority for it to gather data from other federal or private sources, would need congressional action and should be considered also. 

CBO does outstanding work within the rules it has been given. Estimating long-term health effects, and their impact on future federal budgets, is extremely difficult. When combined with congressional rules, such as the Pay-As-You-Go rule requiring offsets for new mandatory spending or revenue reductions, this can have a big impact on how CBO estimates are used for prevention legislation, slowing the opportunity to prevent disease and promote health.

In the long run, this is bad both for the nation’s health and for its health care spending. Small structural changes can improve the Congress’s understanding of cost estimates and lower the barriers to enacting legislation that will improve the health of all who live in the U.S.

The House bill is an important first step.

Dan Crippen served as executive director of the National Governors Association and as a former director of the Congressional Budget Office. Nancy-Ann DeParle is Managing Partner and co-founder of Consonance Capital Partners, and previously served as former Deputy Chief of Staff for Policy in the Obama administration, and as associate director for Health and Personnel at the Office of Management and Budget.