First challenges for a domestic Health Corps

A small army of community outreach workers could help the nation address its major health challenges. Here's a short list that will save lives, and maybe even money.

Less than a month after taking office at the nadir of the Great Depression, President Franklin D. Roosevelt created the Civilian Conservation Corps to help rebuild America. Over the next ten years, the CCC employed over 3 million men (500,000 at its peak) to build dams, restore farmland, plant trees and fight forest fires.

CCC labor also built the nation’s glorious state and national park systems. Its recruits erected over 45,000 bridges and buildings. The CCC provided young workers not just with jobs, but with education and training, which helped them lead happier and more productive lives after returning to the private sector.

In late October 1960, Democratic presidential candidate John F. Kennedy challenged 10,000 students gathered on the University of Michigan campus to do something similar in the international arena. "How many of you who are going to be doctors, are willing to spend your days in Ghana? Technicians or engineers, how many of you are willing to work in the Foreign Service and spend your lives traveling around the world?” he asked.

A little over a month after taking office, JFK signed an executive order creating the Peace Corps. The new agency’s first group of volunteer teachers arrived in Ghana six months later. By the mid-1960s, over 15,000 young men and women, most of them college graduates, were working abroad on two-year rotations. Nearly a quarter million Americans have served in 142 countries since the Peace Corps’ inception. Many subsequently dedicated their lives to public service.

The domestic equivalents – VISTA, created by President Lyndon B. Johnson in 1965; and AmeriCorps, signed into law by President Bill Clinton in 1993 – were modest by comparison. Though hundreds of thousands of VISTA and AmeriCorps volunteers have worked on health, education, housing and social service projects over the years, the scale of funding and programs’ lack of focus never allowed them to leave a permanent mark on American society.

The Biden administration’s latest effort at promoting community service similarly lacks the scope necessary to meet its ambitious goals. The American Climate Corps, established by executive order in September, plans to recruit 20,000 young Americans to work on clean energy and environmental projects, “all while creating pathways to high-quality, good-paying clean energy and climate resilience jobs in the public and private sectors after they complete their paid training program.” Compare that to the number hired by the CCC during the Great Depression, the last time American society faced an existential crisis that not only ruined lives and communities but threatened its democracy.

I’m recounting this history because in my last post, I called for the U.S. to create a permanent pandemic preparedness corps that would also serve at the state and local levels to promote public health. Let’s call it the Health Corps. Should Congress or the White House take up the cause, they need to recognize that it must be of sufficient size to achieve the kind of results that future generations will look back on with admiration.

Existing public health programs are inadequate

There is nothing like that in the health care sector now. The national Public Health Service, created in 1889 to prevent disease, today deploys about 6,000 professionals. For the most part, they work in various federal agencies in health care delivery, conducting research, overseeing regulations, and providing disaster relief. Most of these uniformed public health officers – they are part of the nation’s uniformed services with ranks and titles to match (its leader is the U.S. Surgeon General) – work in Washington, D.C. or at the Centers for Disease Control and Prevention headquarters in Atlanta.

There is one program that provides personnel for the health care sector. The National Health Service Corps, created by Congress in 1970 to address the maldistribution of physicians, provides grants and loans to doctors and other medical professionals to defray the cost of their education in exchange for serving at least two years in underserved areas.

The program’s small budget of about $300 million annually supports just 18,000 clinicians-in-training, far fewer than the number that apply for the program. The service commitment produces about 20,000 trained personnel, who are deployed to rural areas, inner cities and Native American communities that are experiencing severe shortages. They engage mainly in traditional health care delivery and do not work on public health.

No part of the U.S. health ecosystem is more under-staffed than public health, which lost about 50,000 jobs in the decade prior to the pandemic. A recent survey by the de Beaumont Foundation found the U.S. needs to add at least 80,000 workers to the nation’s 3,000 state and local public health agencies, which would represent an 80% increase over current levels, to provide a minimal level of public health services. “That is not inclusive of surge capacity to respond to a pandemic,” said Brian Castrucci, the foundation’s CEO. “During COVID-19, we were surging on a broken foundation.”

During next year’s election season, health care advocates should press the Biden administration, both political parties and candidates at every level to adopt a bold new strategy, one that represents our best chance for meaningfully addressing the escalating number of public health emergencies in this country.

We all know what they are (not in order significance):

Opioid and alcohol abuse; undiagnosed mental health disorders; gun violence; smoking; obesity; untreated diabetes and pre-diabetes; untreated hypertension; untreated chronic kidney disease; undiagnosed, late diagnosed and poorly treated cancers; reproductive health and contraception; infant and maternal mortality; vaccine disinformation and falling vaccination rates; and social stress – the conditions of daily life that drive ill-health such as food, housing and income insecurity.

Creating a Health Corps of 100,000 to 150,000 trained community health outreach workers wouldn’t solve all these problems. But if housed in state and local public health departments with their intimate knowledge of local problems, the Health Corps could devise programs to substantially reduce their incidence in relatively rapid fashion.

It would cost tens of billions of dollars each year, no doubt. And then there’s the cost of follow-up treatments, drugs and social services that would be needed to ameliorate the conditions identified by the community outreach workers.

But not all prevention measures wind up costing more money. A study done nearly two decades ago found about 20% of preventive measures save more money than they cost. More recent cost-effectiveness studies have increased the number of public health interventions that save the system money within the ten-year window that Congress uses to analyze their budget impact.

Here's are five programs that a Health Corps could tackle that I think deserve high priority status. I’m sure my thoughtful readers have their own priorities, which I hope you’ll add through the comments section:

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* Find and treat high blood pressure

Over a third of the U.S. adult population has high blood pressure, largely because of our processed food and salt-laden diets, sedentary lifestyles, and chronic stress. While the decades between 1950 and 2010 saw major reductions in heart attacks and strokes, half of which are caused by uncontrolled hypertension, progress ground to a halt over the past decade. Heart disease remains the nation’s number one killer.

High blood pressure or hypertension can be controlled through lifestyle changes (hard) or medications that are now generic (a lot easier). Only a quarter of people with hypertension have it under control. The American Heart Association reports nearly 35 million people have received blood pressure control prescriptions from their clinicians but never got them filled. Or, they stopped taking the pills, even though these prescriptions have an A rating from the U.S. Preventive Services Task Force and come with no co-pays thanks to the Affordable Care Act.

The nation’s pharmacies could play a major role in solving this undertreatment problem. Pharmacists and other trained professionals could conduct routine hypertension screening at the nation’s 67,000 pharmacies and prescribe generic medicines to those who need it. A program pioneered in Canadian pharmacies, which included six monthly follow-up visits to ensure medication compliance, produced a 50% larger decline in hypertension than relying on usual care through physicians.

A cost-effectiveness study published last month in JAMA estimated that a pharmacy-based program that reached half the population with untreated hypertension could save over $1 trillion in avoided health care costs over the next 30 years. A quarter of that would come in the first ten years because every heart attack and stroke prevented saves tens of thousands of dollars while the generic pills cost pennies.

Of course, there are added costs of paying for pharmacy visits, clinic staffing, and the cost of generic medicines. But the study claimed the intervention would save money in the long run.

But how can we convince people to show up? A massive public service announcement campaign, similar to what was done for COVID-19 vaccines where pharmacies also played a leading role in administering the shots, would make people aware of the service and inform them it was free to consumers. But the most important element would be public health department staffers belonging to the Health Corps showing up in public, visiting workplaces, and knocking on doors to measure blood pressure and conduct the follow-up that assures those identified with hypertension show up for their pharmacy appointment.

* Tobacco cessation for young and old

If you ask cancer experts what accounts for the 33% decline in the cancer death rate since 1991, they will tell you the number one factor was the war on smoking, which began in 1964 when the U.S. Surgeon General stated definitively that smoking tobacco causes cancer. Smoking fell from 43% of the population in 1965 to 14% in 2018. According to the American Lung Association, youth smoking is now under 9%.

There are still a lot of health gains to be had by encouraging those who smoke to stop and preventing more young people from becoming addicted to the nicotine in tobacco products. Members of the Health Corps could conduct education campaigns that reach into every junior high and high school. They could identify those who already smoke and provide cessation counseling and, if necessary, drugs to blunt the craving.

A study that appeared in 2017 in the Annals of Family Medicine found that cessation counseling and drug therapy for those who smoke saves the health care system money in the long run. So does intervening with young people before they begin smoking.

* Testing diabetics for chronic kidney disease

The number one cause of end stage renal (kidney) disease (ESRD) is untreated or poorly managed diabetes. Untreated hypertension is second. These twin epidemics (the two conditions often go together) forces the more than 540,000 Americans with ESRD to submit to thrice-weekly, four-hour sessions on dialysis machines, which mechanically replicate kidney function.

Medicare pays for dialysis, which costs north of $80,000 per patient per year. Though only 1% of Medicare beneficiaries require dialysis, they account for 7% of total Medicare spending. With over 100,000 new ESRD patients beginning dialysis treatment every year (which they will need for the rest of their lives; the average life expectancy once on dialysis is about 5-7 years), there are huge savings and lengthened lives to be gained by shrinking the number of people flowing into dialysis.

Achieving those goals requires finding and treating all diabetics and hypertension patients who are at the beginning stages of their kidney disease. Only 10% of people with kidney disease know they have it, largely because only 40% of diabetics are screened for the disease.

“There’s a whole bunch of things we can do. We can we use dialysis to motivate them to take care of themselves, to have more physical activity and eat a more balanced diet,” said Dr. Joseph Vassalotti, the chief medical officer for the National Kidney Foundation. “We have medications for people with diabetes who have kidney disease, all generic and relatively inexpensive.”

The problem is getting people who are at risk of developing ESRD screened. Here’s where the Health Corps could play the vital outreach role. There are simple tests that look for elevated protein levels in the blood and urine, the markers of early-stage kidney disease. They could be administered at peoples’ homes with return visits scheduled for those who test positive to encourage them to visit their physician or local pharmacy to get treated – and stay treated.

A study published earlier this year suggested physicians providing mass screening for chronic kidney disease when people turn 55 would cost around $86,000 per quality-adjusted-life-year gained. Turning the task of testing, prescribing and follow-up to ensure compliance to public health departments’ Health Corps and local pharmacies would sharply reduce that figure, and would be well worth the effort in terms of improved population health.

* De-stigmatize and treat substance abuse

The number of opioid-overdose deaths in the U.S. rose from 21,000 in 2010 to more than 80,000 in 2021. Alcohol-related diseases cost 140,000 people their lives every year, making it one of the leading causes of death. Both afflictions are devastating communities and families. Substance abusers are filling the prisons. And treating substance abuse is costing private health insurers (most substance abusers are under age 65) over $35 billion a year.

Only a third of the estimated half million drug addicts receive counseling, treatment or engage with harm reduction strategies. Less than 5% of the 1.4 million people with diagnosed alcohol-abuse disorder receive counseling and treatment.

But recent research on the cost-effectiveness of various substance abuse interventions showed organizing a comprehensive harm reduction approach can save lives and reduce crime, hospitalizations and ER visits. Harm reduction strategies include improved access to naloxone, the antidote to an opioid overdose; needle exchanges; supervised injection facilities; and drug checking to screen for fentanyl, the opioid responsible for the most deaths. Treating alcohol abusers who’ve already shown signs of cirrhosis of the liver with counseling and medication actually saves the system money.

The Health Corps could play the key role in identifying substance abusers in the community, reaching out to provide counseling and treatment, and staffing the facilities that offer harm reduction services.

Of course, other research has shown that the most effective “treatment” for substance abuse is ending the social decay that has made it so prevalent in contemporary U.S. society. Others have pointed out that political interventions like banning alcohol advertising, limiting retail sales hours and levying higher taxes not only saves lives, they reduce health care expenditures.

* Prenatal and maternal care

America’s unacceptably high infant and maternal mortality rates, disproportionately affecting the nation’s African-American population, could be readily addressed through a national Health Corps.

States could use public service announcements and deploy outreach workers to identify every pregnant woman and her immediate family to ensure they have prenatal care, guidance through the birthing experience and education about the importance of providing the newborn with a positive early childhood experience. States without punitive restrictions on abortion and other reproductive health services could have their Health Corps workers offer those services as well.

Numerous studies have shown prenatal interventions with mothers, especially those at greatest risk of low birthweight babies or gestational diabetes, is effective at reducing other health care costs. More importantly, it will help reduce the nation’s outrageously high infant mortality rate.

I have tried to think broadly in creating this list. Perhaps you have your own suggestions and study citations. Please let me know. I may write about them in the coming weeks.