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Improving Americans’ Nutrition Security Requires Legislative Action

Q&A with Dr. Hilary Seligman:

Hilary Seligman, M.D., MAS, is a professor at the University of California, San Francisco, with appointments in the Departments of Medicine, Epidemiology, and Biostatistics. Her research and advocacy work focuses on food insecurity, its health implications, and the needed policy responses.

TFAH: Food insecurity is obviously a serious problem in the United States. Can you also talk about the issue of nutrition insecurity and the relationship between the two?

Dr. Seligman: First, it’s important to recognize that the food-security construct always considered access to nutrition, not just calories. But, the sector’s new focus on nutrition security has helped emphasize the importance of providing not just food but food that meets people’s health and nutrition needs. The construct of nutrition security is also strongly related to issues of equity and the massive burden of early mortality in our country that is related to poor diets.

TFAH: Can food banks and charitable food networks address hunger and improve nutrition?

Dr. Seligman: Yes, of course they can, and they must. The charitable food system as a whole has made massive investment and progress in this area over the last decade. What I do want to call attention to though is that the same forces that make it difficult for individuals to afford and prepare healthy food make it difficult for the charitable food system to distribute healthy food. Healthy alternatives almost always cost more, they are often perishable, and they often require more preparation time which can be costly to provide. So, although there has been strong investment and tremendous progress at the system level, there is still a lot to be done. It will always be cheaper to distribute a box of mac and cheese than it will be to distribute a peach.

TFAH: You’ve been a leader in grassroots anti-hunger programs in the San Francisco area, programs like EatSF, a healthy food voucher program. Are these programs making a difference in food insecurity for San Francisco families and children?

Dr. Seligman: EatSF is one of a rapidly growing ecosystem of state and local food voucher programs and produce prescription programs in the U.S. These programs have functioned as a way for local leaders and health systems to say: We see we have this critical problem of nutrition insecurity in our community, this is not acceptable in the richest county in the U.S., and we are going to do something about it. I think that is amazing, and I am privileged to be a part of that movement. But, let’s be honest, the nutrition security problem in the U.S. is not going to be solved by small local programs. We need a systems-based approach. We need better policies to address nutrition security, and we need to rectify the way in which our current policies work better for white people than they do for people who are not white.

TFAH: Can you say more about that? How does current policy work better for white people than for people of color?

Dr. Seligman: SNAP program policies are a good example. In order for able bodied adults to receive SNAP benefits they have to be working. For a myriad of reasons, Black people are less likely to be able to secure employment. They are therefore less likely to be able to meet the work requirements that would allow them to enroll in SNAP, even if they are food insecure.

TFAH: You direct the National Clinician Scholars Program at the UCSF School of Medicine. The goal of the program is to train clinicians to be change-agents in order to improve their patients’ health. Are clinicians and the healthcare system doing enough to address the social determinants of health? Are they well-prepared to treat their patients who have obesity?

Dr. Seligman: Traditionally, healthcare in the U.S. has focused on treating, not preventing, disease in individuals. The evidence is very clear that this is the worst way to approach obesity: first to do it at the treatment stage (when obesity has already developed, rather than to prevent the onset of obesity) and second to do it by attempting to change people’s behaviors, rather than changing the environments that resulted in the onset of obesity to begin with. So, although I hate that we need to be having this discussion at all, we do. We do because the U.S. has completely failed at prevention efforts and at policy and environmental approaches to obesity prevention for decades. So now, what needs to be done? Obesity and poor diets are the biggest drivers of healthcare costs in the country— so the healthcare system has to get involved (whether it is traditionally in their wheelhouse or not), and the best way to do this is by addressing social determinants of health and food environments. It is not a comfortable fit for the healthcare system, but there really is no other choice. And because it is not a comfortable fit and requires a new way of thinking about healthcare and new kinds of engagement and policy change, we have to nurture the next generation of healthcare leaders to be able to tackle these really complicated problems.

TFAH: What are the links between public policy and obesity? What policy actions or changes would you like to see enacted?

Dr. Seligman: Oh, there are so many of them—dozens if not more are being discussed as potential approaches for the next Farm Bill. At the federal level alone, there are policy levers that Congress, USDA, and the FDA have authority over that could help reverse obesity trends. Let’s start with an enormous one: SNAP. Early in my career I worked on health literacy, and I was always challenged by the lack of existing infrastructure to reach people with effective health literacy interventions. Food insecurity is not like that. SNAP works. It reaches almost 50 million people in the U.S. annually. It is available in every county nationwide. It helps families to afford more nutritious food. So, we have the tools, we have the evidence, and we have the infrastructure to solve food insecurity in the U.S. What we lack is the political will. We need to expand SNAP eligibility to all the people who aren’t receiving the food they need but who are not currently eligible for benefits, and we need to raise benefit rates to allow for the purchase of healthy food. If these changes are made, it is very clear to me that they will have a substantial impact on obesity rates and on public health.

TFAH: There were a number of waivers in federal food programs like SNAP, WIC, and school meals, during the COVID-19 pandemic to better reach individuals and families during the public health emergency. Are there any lessons we can learn from these policy changes?

Dr. Seligman: Yes! The predominant lesson is: these programs work. Food insecurity rates did not increase nearly as much as anticipated during the pandemic, although there were certainly vast disparities in how the pandemic impacted different communities. Why didn’t rates of food insecurity rise as much as anticipated? Because we had the will to do the things we knew—based on a tremendous amount of evidence— would make a difference. When we make it easier for people to enroll in SNAP, more people have access to benefits and food insecurity falls. When we provide money on debit cards to replace the meals not being served in schools, food insecurity falls. When stimulus checks were sent to people across the U.S. in response to the pandemic, low-income households reported that food was the first or second most covered item from the stimulus money.

The really optimistic lesson is that we know how to address hunger, nutrition security, and obesity prevention through good public policy. Now we just have to keep these programs in place as interest in the pandemic wanes.

Additional Resources:

Brief: Legislative Priorities for the 118^th Congress

Report: State of Obesity 2022

Priority Issue: Obesity /Chronic Disease

This interview was originally published as a part of TFAH’s 2022 State Of Obesity: Better Policies for a Healthier America report.

Legislative Priorities for the 118th Congress

TFAH’s Board Chair and President and CEO, Statement in Honor of Martin Luther King, Jr. Day and the National Day of Racial Healing

“Today’s observation of Martin Luther King, Jr. Day and tomorrow’s National Day of Racial Healing are a time to take action to end racism, heal the impacts of centuries of racial injustice, and promote equity for all people.

As the COVID-19 pandemic has demonstrated, long-standing structural racism within our society causes a disproportionate negative impact on people of color, especially during public health emergencies.

TFAH’s goal is to secure the opportunity for optimal health for everyone and make all communities more resilient. This includes advancing policies that promote health and address the primary drivers of health disparities.

We are committed to continuing to support and advocate for policies that overcome the impacts of racism and advance health equity. Meaningful change will require racial healing, which will in turn necessitate acknowledging the historical and contemporary impacts of racism, building meaningful relationships across communities, and policy change.”

Among TFAH’s policy priorities for promoting health equity in 2023 are the following:

Invest in policies and capacity to address the social determinants of health: Congress should fund the Centers for Disease Control and Prevention’s Social Determinants of Health work to enable communities to work across sectors to address the non-medical drivers of poor health outcomes.

Target the elimination of poverty by implementing living wage policies and expanding the Earned Income Tax Credit at the national and state levels.

Strengthen leadership for health equity and incorporate lessons learned from the COVID-19 pandemic into future preparedness and response capabilities. The White House, Congress, and relevant federal, state, local, tribal, and territorial agencies should continue to implement the recommendations of President Biden’s COVID-19 Health Equity Task Force. The White House should create a permanent health equity infrastructure to implement and ensure accountability for these recommendations and bolster equity leadership and coordination for future health crises.

Provide job-protected paid leave. The pandemic called attention to the fact that paid family, sick, and medical leave protect individual’s and families’ economic security and are important infection-control measures. Congress should enact a permanent federal paid family and medical leave policy and dedicated paid sick days protections, including for preventive services such as vaccination.

Congress and federal agencies should ensure federal funding is reaching localities and organizations that represent and serve communities that encounter disproportionate barriers to good health.

Public health agencies should appoint chief health equity officers who would be part of the response, planning, and activation teams for all emergencies.

Increase access to high-quality healthcare for all by strengthening incentives to expand Medicaid and by making marketplace coverage more affordable for people with low- and moderate-incomes.

Increase funding for programs that promote long-term security and good health for children and families, including programs designed to expand access to affordable housing and Head Start, Early Head Start, and nutrition support programs such as Healthy School Meals for All, the Supplemental Nutrition Assistance Program (SNAP), and the Special Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC).

For more information, see TFAH’s reports.

Trust for America’s Health is a nonprofit, nonpartisan organization that promotes optimal health for every person and community and works to make the prevention of illness and injury a national priority. www.tfah.org

The National Day of Racial Healing, is sponsored by the W.K. Kellogg Foundation. According to the Foundation, the day is a time to contemplate our shared values and create a blueprint for #HowWeHeal from the effects of racism. W.K. Kellogg Foundation (wkkf.org)

Fairfax County, Virginia Community Health Workers Program Supports COVID-19 Isolation and Quarantine Adherence in Minority Communities

(Washington DC, January 9, 2023) Throughout the COVID-19 pandemic communities nationwide have struggled to control the spread of the virus. Barriers to limiting virus spread were particularly acute in communities where a significant proportion of the population lived near or below the poverty line or were not English proficient. Fairfax County, Virginia is an example.

The Fairfax County Health Department (FCHD) is the largest health department in the state, serving 1.2 million residents. Fairfax Country, a suburb of Washington, DC is a relatively wealthy community based on national averages, but 15 percent of its population lives below the poverty line and 40 percent of county residents are non-English speakers. State data showed that Black and Hispanic county residents were 2.9 and 1.6 times more likely to contract the virus, respectively, than their non-Hispanic, white co-residents. Moreover, Hispanic ethnicity, contact with a case, and household crowding were analyzed as independent risk factors for infection.

In response, the county health department expanded its small, traditional community health worker program to a full-fledged pandemic response team the make-up of which was designed to be culturally and language competent and relatable to the county’s minority communities in order to share information and build trust. The task of the community health team was to increase isolation and adherence protocol within minority households in order to decrease the rate of infection for the most at-risk groups within the county.

Community outreach programs are rooted in earlier emergency events

After 9/11, H1N1, and Ebola state and local health departments across the country recognized the need to prepare all-hazards approaches to public health emergencies. FCHD did so by formulating a pandemic response plan working with various community engagement partners. These established relationships helped jump start the community health worker COVID-19 program. County health officials knew that a major contributor to adherence to isolation and quarantine (I&Q) protocols would be meeting families’ basic needs, including for groceries, medicines, and transportation to medical appointments. FCHD strategically recruited and trained their large CHW team to focus on meeting those needs when a family had a COVID exposure or infection.

The Results of the Community Health Worker Program

To assess whether its expanded community health worker program was successful Fairfax County Health conducted a 6-month, cross-sectional study contacting 1,500 individuals, 800 of whom were served by a community health worker (CHW) between February and July 2021, and 700 individuals served as controls who did not receive CHW assistance. Results were based on 161 individuals in the CHW recipient group and 179 individuals in the control group who were surveyed. Of the group of CHW recipients, most were COVID-19-positive, Hispanic, and female. Most of the services provided fell under the umbrella of basic needs, such as information, hygiene, groceries, and cleaning supplies. Of those receiving services, a large majority, 87 percent, reported satisfaction with the program.

Reducing the rate of people who were COVID-19 exposed or infected leaving their home was one of the program’s main goals. Persons who received CHW services during their isolation and quarantine (I&Q) period experienced a significantly lower frequency – 30.7 percent left the house at least once during their I&Q compared with 43.9 percent among controls. 64.3 percent of those assisted by a CHW who left home did so to see a doctor or pick up medications. Of those who left their homes during I&Q, persons that received CHW services, left 2.4 times on average compared with 6.2 times among controls.

Sustainability of the Community Health Worker Program

In August of 2022, the Fairfax County Health Department was only one of four local health departments nationally that received a National Association of County and City Health Officials (NACCHO) 2022 Gold Innovative Practice Award in recognition of its strategic community health worker program development and implementation during the COVID-19 pandemic.

Going forward, Fairfax health officials realize that these types of programs must be continuously refined and measured so they can be upheld as evidence-based programs that should not only operate during emergencies but in traditional public health roles as well.

According to Chris Revere, the Fairfax County Health Department Deputy Director for Innovation and Planning, sustaining the expanded community health worker program will require a substantial amount of financial investment, especially from the federal government; federal funds supported the expansion of the program during the pandemic. In 2022, the Centers for Disease Control and Prevention received $3.2 billion in funding to strengthen the public health workforce and infrastructure. According to Virginia state officials, roughly $67 million of those funds are headed to the Virginia Department of Health. From there, statewide grant distributions to local health departments will be coordinated. Revere called the anticipated funding a “great start” but must be “built into baseline budgets.” Moreover, Mr. Revere stressed that policymakers need to understand that public health funding has been inadequate for over a decade. What’s needed going forward is a decade-plus investment to ensure the sustainability of future community health worker programs, says Revere.

Conclusion

While the COVID-19 pandemic demonstrated the nation’s critical need to increase and sustain funding in public health emergency preparedness it also highlighted the need for innovation in programs to support preparedness particularly within low-income and minority communities. The Fairfax County community health workers program is an example of an initiative that should be sustained and replicated in other localities.

Trust for America’s Health is a Healthy People 2030 Champion!

As an organization that prioritizes optimal health for all people, Trust for America’s Health (TFAH) is pleased to be recognized as a Healthy People 2030 Champion by the U.S. Department of Health and Human Services (HHS). TFAH shares the Healthy People 2030 vision of a society in which all people can achieve optimal health and well-being across the lifespan. This commitment is reflected in TFAH’s overall vision and mission and within its Age-Friendly Public Health Systems (AFPHS) initiative. TFAH prioritizes achieving equity in all of our work and promotes optimal well-being for all by focusing on the social determinants of health (SDOH).

TFAH has worked closely HHS leadership, particularly within the Office of Disease Prevention and Health Promotion, which administers Healthy People 2030, to promote stronger collaborations between state departments of health and state aging agencies.

The Age-Friendly Public Health Systems initiative and Healthy People 2030 are well aligned as they share a focus on optimal health in every community. AFPHS’s 6C’s strategy provides a roadmap for state and local health departments to engage in activities that support healthy aging in their communities including:

Connecting and convening multi-sector stakeholders

Coordinating existing supports and services

Collecting, analyzing, and translating relevant data

Communicating important public health information

Complementing existing health promoting programs

Creating and leading policy, systems, and environmental changes

In addition to the Healthy People 2030/AFPHS alignment, TFAH supports the Healthy People 2030 vision in the following ways:

Promoting and increasing access to disease prevention and health promotion activities.

TFAH’s federal advocacy priorities focus on strengthening the public health system so that every state, tribal, local, and territorial health department has the funding and capacity to improve and sustain optimal health for every person and community.

Addressing social determinants of health, eliminating disparities, achieving health equity, and/or promoting well-being.

TFAH is leading advocacy efforts to increase public health’s capacity to fully address the social determinants of health, with a focus on equity and eliminating disparities in health across the lifespan.

Providing training and other necessary resources to adapt or modify disease prevention and health promotion activities to meet the needs of diverse populations, address SDOH, eliminate disparities, achieve health equity, and/or promote well-being.

Many of TFAH’s reports and policy briefs document states where health promotion activities need improvement, as well as feature best practices. In addition, TFAH’s website includes detailed health data on every state and territory including on emergency preparedness, prevalence of chronic diseases and flu vaccination rates.

Developing partnerships across a variety of sectors, including public health, healthcare, government, philanthropy, civil rights, academia, education, community, faith-based, media, business, and technology

TFAH routinely hosts convenings of representatives across sectors including public health, healthcare, government, philanthropy, academia, community, and education. Such convenings have focused on the COVID-19 pandemic, adolescent health, healthy aging, state policies to promote health and control costs, and many other topics.

TFAH looks forward to continuing our strong partnership with the HHS Office of Disease Prevention and Health Promotion and other Healthy People 2030 Champions to create and sustain opportunities for all Americans to live healthfully and productively throughout their lives.

New CDC Data Shows 4 Percent Rise in Suicides in 2021

On September 30, the Centers for Disease Control and Prevention (CDC) released a new report on provisional data on suicide mortality in 2021. The new data shows a 4 percent increase in the national suicide rate—rising from 13.5 deaths per 100,000 population in 2020 to 14.0 deaths per 100,000 population in 2021. In contrast, the national suicide rate declined in both 2019 and 2020, though it had steadily increased over the previous two decades.

The report also includes additional information on suicide by sex, age group, and month. Key takeaways:

Suicide rates increased more among males (3 percent increase) than females (2 percent increase).
Suicide rates increased for people in nearly all age groups. The only exception was a 2 percent decline for people age 75 and over, though it was not a statistically significant change.
The largest statistically significant increase among all sex/age groups was for males aged 15–24, with an 8 percent increase in suicide rate from 2020 to 2021. Females aged 10–14 had the largest percentage increase in suicide rate (15 percent), though the change was not statistically significant due to a relatively small numbers of cases.
There were more suicides across all months of 2021 compared with 2020, except in January, February, and July. The largest increase across all the months was an 11 percent increase in suicide rate in October.

The report does not include racial/ethnic or geographic information, nor information on suicide method—all critical pieces to understanding the full picture. For example, data from 2020 showed higher rates of suicide among American Indian, Black, and Latino people and of suicide by firearm—all in a year when the overall suicide rate declined. The National Center for Health Statistics will likely release final 2021 mortality data, including these additional data points, in December.

“The increase in suicide is devastating,” said J. Nadine Gracia, M.D., MSCE, President and CEO of Trust for America’s Health (TFAH). “The new data underscores the need for more attention on this issue and action to prevent future suicides—by federal policymakers, the private and non-profit sectors, and every community across the nation. This study is a wakeup call that we continue to face a mental health and substance use crisis, but we can prevent these tragic deaths.”

The most recent Pain in the Nation report from TFAH includes 2020 data and an analysis of longer-term trends, as well as policy recommendations for reducing alcohol, drug, and suicide deaths. The new CDC report reaffirms the importance of many of these recommendations, including to:

Strengthen the continuum of crisis intervention programs with a focus on the newly established “988” lifeline.
Expand CDC’s comprehensive suicide-prevention efforts, including measures to strengthen economic supports, promote connectedness, and create protective environments.
Address the social determinants of health and promote resilience in children, families, and communities, including through economic supports, access to quality childcare, and prevention and early intervention efforts in schools.
Build grassroots community capacity for early identification and intervention for individuals with mental health and substance use disorders, including through community-based or non-traditional settings.
Limit access to lethal means of suicide, including drugs and firearms, among individuals at higher risk of suicide through state and federal laws, more funding of foundational research, and the adoption of counseling programs in healthcare systems.

New CDC Data Shows 4 Percent Rise in Suicides in 2021

The report also includes additional information on suicide by sex, age group, and month. Key takeaways:

Suicide rates increased more among males (3 percent increase) than females (2 percent increase).
Suicide rates increased for people in nearly all age groups. The only exception was a 2 percent decline for people age 75 and over, though it was not a statistically significant change.
The largest statistically significant increase among all sex/age groups was for males aged 15–24, with an 8 percent increase in suicide rate from 2020 to 2021. Females aged 10–14 had the largest percentage increase in suicide rate (15 percent), though the change was not statistically significant due to a relatively small numbers of cases.
There were more suicides across all months of 2021 compared with 2020, except in January, February, and July. The largest increase across all the months was an 11 percent increase in suicide rate in October.

Strengthen the continuum of crisis intervention programs with a focus on the newly established “988” lifeline.
Expand CDC’s comprehensive suicide-prevention efforts, including measures to strengthen economic supports, promote connectedness, and create protective environments.
Address the social determinants of health and promote resilience in children, families, and communities, including through economic supports, access to quality childcare, and prevention and early intervention efforts in schools.
Build grassroots community capacity for early identification and intervention for individuals with mental health and substance use disorders, including through community-based or non-traditional settings.
Limit access to lethal means of suicide, including drugs and firearms, among individuals at higher risk of suicide through state and federal laws, more funding of foundational research, and the adoption of counseling programs in healthcare systems.

State of Obesity 2022: Better Policies for a Healthier America

Nation’s Obesity Epidemic is Growing: 19 States Have Adult Obesity Rates Above 35 Percent, Up From 16 States Last Year

Social and Economic Factors Are Key Drivers of Increasing Obesity Rates

(Washington, DC – September 27, 2022) – Four in ten American adults have obesity, and obesity rates continue to climb nationwide and within population groups, according to a report State of Obesity 2022: Better Policies for a Healthier America released today by Trust for America’s Health (TFAH). The report amplifies the importance of the White House Conference on Hunger, Nutrition and Health happening tomorrow. The Conference and the report are intended to spotlight the links between hunger, nutrition, and health, and diet-related diseases including obesity. In addition, they will drive policy action to address food insecurity and health disparities, factors often at the root of diet-related health issues.

The report finds that persistent increases in obesity rates across population groups underscores that obesity is caused by a combination of factors including societal, biological, genetic, and environmental, which are often beyond personal choice. The report’s authors conclude that addressing the obesity crisis will require attending to the economic and structural factors of where and how people live.

Based in part on newly released 2021 data from the Centers for Disease Control and Prevention’s Behavioral Risk Factors Surveillance System, and analysis by TFAH, the report tracks rates of overweight and obesity by age, race/ethnicity, and state of residence. Among the most striking findings are:

Nineteen states have adult obesity rates over 35 percent. West Virginia, Kentucky, and Alabama have the highest rate of adult obesity at 40.6 percent, 40.3 percent, and 39.9 percent, respectively. The District of Columbia, Hawaii, and Colorado had the lowest adult obesity rates at 24.7 percent, 25 percent, and 25.1 percent respectively.

A decade ago, no state had an adult obesity rate at or above 35 percent. (See state-by-state rate chart).

National data from the 2017-2020 National Health and Nutrition Examination Survey also included in the report show the following:

Nationally, 41.9 percent of adults have obesity.
Black adults had the highest level of adult obesity at 49.9 percent.
Hispanic adults had an obesity rate of 45.6 percent.
White adults had an obesity rate of 41.4 percent.
Asian adults had an obesity rate of 16.1 percent.
Rural parts of the country had higher rates of obesity than did urban and suburban areas.

Structural and social determinants are significantly influencing the rates of obesity among adults and youth. Factors such as structural racism, discrimination, poverty, food insecurity, housing instability, and lack of access to quality healthcare are key drivers of the differences in obesity rates across racial and ethnic groups. These systemic barriers make it inappropriate to assign blame to individuals with obesity for their weight. The purpose of this report is to analyze conditions in people’s lives which make them more likely to develop obesity and recommend policies to address those conditions.

Obesity rates are also increasing among children and adolescents with nearly 20 percent of U.S. children ages 2 to 19 having obesity. These rates more than tripled since the mid-1970s and Black and Latino youth have substantially higher rates of obesity than do their white peers.

A special section of the report looks at the relationship between food insecurity and obesity. Food insecurity, defined as being uncertain of having or unable to acquire enough food because of insufficient money or resources, is driven by many of the same social and economic factors that drive obesity including poverty and living in communities with many fast-food establishments but limited or no access to healthy, affordable foods such as available in full-service supermarkets or farmers markets. Being food and nutrition insecure often means families must eat food that costs less but is also high in calories and low in nutritional value.

Obesity is multifactored and involves more than individual behavior

Social and economic factors including experiencing poverty and the impact of long-standing structural racism and health inequities are strongly associated with obesity and are at the root of higher rates of obesity in low-income communities that have fewer resources to support healthy eating and being physically active.

“The continued increase in rates of obesity across all population groups is alarming,” said J. Nadine Gracia, M.D., MSCE, President and CEO of Trust for America’s Health. “Policies and programs to reduce obesity need to be implemented at a systems level. We must advance policies that address the community, institutional, and structural factors that are barriers to healthy eating and physical activity and that exacerbate health inequities.”

Addressing obesity is critical because it is associated with a range of diseases including type 2 diabetes, heart disease, stroke, arthritis, sleep apnea, and some cancers. Obesity is estimated to increase U.S. healthcare spending by $170 billion annually (including billions by Medicare and Medicaid).

The report includes recommendations for policy actions that federal, state, and local policymakers and other stakeholders should take including:

Increase funding for the CDC’s National Center for Chronic Disease Prevention and Health Programs to prevent obesity and related chronic diseases. Funding increases need to be sufficient to put proven obesity prevention programs to work in every state and should prioritize those communities where the need is greatest to address health inequities.
Make healthy school meals for all students a permanent policy, extend COVID-19 flexibilities that expand nutrition access for students and their families, strengthen school nutrition standards, and increase students’ opportunities for physical activity during the school day.
Expand the CDC’s social determinants of health program to address the upstream, structural drivers of chronic disease.
Decrease food insecurity and improve the nutritional quality of available food by increasing funding for and participation in nutrition assistance programs such as the Supplemental Nutrition Assistance Program (SNAP), the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and the Child and Adult Care Food Program.
End unhealthy food marketing to children by closing tax loopholes and eliminating business-cost deductions related to the advertising of unhealthy food and beverages to young people.
Impose excise taxes on sugary drinks and devote the revenue to local obesity prevention programs and to reduce health disparities.
Expand support for maternal and child health, including supporting breastfeeding.
Fund active transportation projects like pedestrian and biking paths in all communities and make local spaces more conducive to physical activity such as opening school recreational facilities to community groups outside of school hours.
Expand access to healthcare and require insurance coverage with no cost sharing for U.S. Preventive Task Force recommended obesity prevention programs.

Read the full report

New Report: Nation’s Chronic Lack of Investment in Public Health Puts Americans’ Lives and Livelihoods at Risk

COVID-19 emergency funding was critical to initial pandemic response but did not address nation’s long-standing underinvestment in public health; $4.5 billion in annual infrastructure funding is needed

(Washington, DC – July 28, 2022) – Chronic underfunding has created a public health system that cannot address the nation’s health security needs, its persistent health inequities, as well as emerging threats, and, was a contributing factor in the inadequate response to the COVID-19 pandemic, according to a report, The Impact of Chronic Underfunding on America’s Public Health System: Trends, Risks, and Recommendations, 2022, released today by Trust for America’s Health.

Lack of funding in core public health programs slowed the response to the COVID-19 pandemic and exacerbated its impact, particularly in low-income communities, communities of color, and for older Americans – populations that experience higher rates of chronic disease and have fewer resources to recover from an emergency. TFAH is one of numerous organizations within the public health community calling for an annual $4.5 billion investment in public health infrastructure at the state, local, tribal, and territorial levels.

This annual report examines federal, state, and local public health funding trends and recommends investments and policy actions to build a stronger public health system, prioritize prevention, and address the ways in which social and economic inequities create barriers to good health in many communities.

“As we navigate the next stages of the pandemic and beyond, it is critical that we modernize public health data infrastructure, grow and diversify the public health workforce, invest in health promotion and prevention programs, and reduce health inequities. Investments in public health are needed in every community but should particularly be directed to those communities, which due to the impacts of structural racism, poverty, systemic discrimination, and disinvestment are placed at greatest risk during a health emergency,” said Dr. Gracia.

Emergency funding is not sufficient to address system weaknesses created by chronic underfunding

State and local public health agencies managed two divergent realities during 2021. Short-term funding was up significantly as the federal government provided funding to states and localities in an effort to control the pandemic. But this funding was one-time money and often specifically tied to COVID-19. Most of it could not be used to address longstanding deficits in the public health system, including ensuring the provision of basic public health services, replacing antiquated data systems, and growing the public health workforce. An October 2021 analysis conducted by the de Beaumont Foundation and the Public Health National Center for Innovations, found that state and local health departments need an 80 percent increase in the size of their workforce to be able to provide comprehensive public health services to their communities.

Another challenge for state and local health departments is that emergency response funding, while critical during the emergency, is too late to build prevention and preparedness programs, programs that must be in place before an emergency if they are going to protect lives. To be adequately prepared for the next public health emergency, the nation needs to sustain higher levels of public health funding and provide more flexible funding.

“Emergency funding is important but not sufficient to fill the longstanding gaps in public health investments. The ‘boom-and-bust’ cycle of public health funding has meant that the system does not have the tools or workforce to modernize and respond to the range of threats impacting our communities,” said J. Nadine Gracia, M.D., MSCE, President and CEO of Trust for America’s Health.

Funding for two key emergency preparedness and response programs are down sharply over the past two decades:

The U.S. Centers for Disease Control and Prevention (CDC) is the country’s leading public health agency and the primary source of funding for state, local, tribal, and territorial health departments. CDC’s annual funding for Public Health Emergency Preparedness (PHEP) programs increased slightly between FY 2021 and FY 2022, from $840 million to $862 million, but has been reduced by just over one-fifth since FY 2002, or approximately in half when adjusted for inflation.
The Hospital Preparedness Program, administered by the U.S. Department of Health and Human Services’ Office of the Assistant Secretary for Preparedness and Response, is the primary source of federal funding to help healthcare systems prepare for emergencies. It has experienced a nearly two-thirds reduction over the last two decades when adjusted for inflation.

Funding for health promotion, prevention, and equity also need sustained growth

As a nation, we spent $4.1 trillion on health in 2020 but only 5.4 percent of that spending targeted public health and prevention. Notably, this share nearly doubled last year as compared to 2019 – due to short-term COVID-19 response funding – but is still grossly inadequate and likely to return to pre-pandemic levels if the historic pattern of surging funding for public health during an emergency but neglecting it at other times resumes. Inadequate funding means that effective public health programs, such as those to prevent suicide, obesity, and environmental health threats, only reach a fraction of states. This longstanding neglect contributes to high rates of chronic disease and persistent health inequities.

Recommendations for policy actions

The report calls for policy action by the administration, Congress, and state and local officials within four areas:

Substantially increase core funding to strengthen public health infrastructure and grow the public health workforce, including increasing CDC’s base appropriation and modernizing the nation’s public health data and disease tracking systems.

Invest in the nation’s health security by increasing funding for public health emergency preparedness, including within the healthcare system, improving immunization infrastructure, and addressing the impacts of climate change.

Address health inequities and their impact on root causes of disease by addressing the social determinants of health that have an outsized impact on health outcomes.

Safeguard and improve health across the lifespan. Many programs that promote health and prevent the leading causes of disease, disability, and death have been long neglected and do not reach all states or the populations most at risk. Reinvigorating programs that stem chronic disease, support children and families, and prevent substance misuse and suicide should be a top priority.