To understand how the US budget process disincentivizes long term public health investment it is important to first know the 4 types of spending.
| Spend Now Benefit Now | |
| Spend Now Benefit Later |
| Spend Later Benefit Now |
| Spend Later Benefit Later |
Based on our political process the spend later benefit now approach is highly incentivized. This entails adding to the national debt for a current benefit. Politicians are driven to give their electors promises of services without added taxes in order to get and stay elected. The issue with this infrastructure is that it disincentives long term investments such as preventative public health measures and burdens future generations with costs they don’t benefit from.
I am currently also in a federal and state budget seminar at the law school (taught by Professor Lawrence, head of the health law program) and we have discussed this issue a lot. One of the solutions we keep coming back to is setting legislation to take affect around 10 years in the future surrounding reducing deficit spending or investments. This method allows for whatever party is in power to not tie the decision to their political capital. One hurdle with this is an issue called entrenchment, which is basically taking decision making out of the hand of future officials.
I’d be interested to hear about approaches to solve this issue from a public health perspective. As we saw with the COVID-19 pandemic underinvestment in public health measures is a huge issue and due to that we are further burdening future generations with the debt that resulted from expenditures.
Hey Payton! Thank you for bringing this topic up. I find this issue coming up in another field of thought- climate change. I believe one of the major roadblocks to climate change initiatives is the inability to think long-term. Politicians are interested in gaining votes and it is hard for anyone to think about the future 10, 15, 20 plus years down the line.
While I don’t know if I have any solid solutions to this question on public health matters, I often think about HIV prevention measures and PrEP. In 2019 PrEP was recommended by USPSTF (US Preventative Services Task Force) to be offered at no cost by most insurances and Medicaid programs because of its value in preventing transmission. This of course, costs the public money, but is so essential to HIV prevention methods. Unfortunately, there have been debates about this and I believe even went to court in Texas.
Interesting post Payton, I wish we had time to dig deeper into what you are learning in your law school class. I think Ilse’s connection to climate change is a good one. We are really paying dearly now for decisions that were made in the past.