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Effectiveness in Disease and Injury Prevention Estimated National Spending on Prevention -- United States, 1988

Despite the overall health improvements achieved through preventive interventions, the United States continues to be burdened by preventable illness, injury, and disability (1). For example, annual health-care expenditures for cardiovascular disease alone exceed $135 billion and injury and disability, $170 billion (1). This report summarizes the findings of a study to estimate national funding for health promotion and disease prevention in the United States during 1988 (2).

The Health Care Financing Administration (HCFA) annually estimates the total national expenditures on health in the national health accounts (NHA) * (3). The NHA is the benchmark for determining the amount and growth of spending on health and for characterizing what services and products are purchased and the sources of payment. However, NHA information on prevention expenditures is limited because of cost definitions, demarcations between categories, and the availability and accuracy of secondary data sources. Further, NHA does not include all spending on prevention. For example, certain prevention programs such as environmental health, sewer and water systems, and social programs (e.g., the Supplemental Food Program for Women, Infants, and Children) that have a health component are not included in NHA. Therefore, a comprehensive estimate of spending on prevention in the United States requires additional assumptions and additional data sources.

For this study (3), prevention was defined as activities that reduce the incidence, prevalence, and burden of disease and injury and enhance health by improving physical, social, and mental well-being. The three categories of prevention are health promotion, health protection, and preventive health services (1). Health promotion activities influence personal health behaviors; health protection changes the social and physical environment to restrict personal exposures; and preventive health services offer counseling, screening, and vaccination in clinical settings.

To document all such sources of prevention funding, data were examined by funding sources ** (2,4), including federal, state, and local government programs; voluntary health associations; corporations and foundations; worksite programs; and personal prevention services.

Based on this review and analysis, CDC estimates that in 1988 the total spending on prevention in the United States was $32.8 billion (0.7% of the gross national product (GNP)). Approximately half ($15.7 billion (48%)) of this was spent by the federal government; personal spending and insurance spent nearly one third ($10.0 billion (31%)); state governments, $3.7 billion (11%); and local governments, $2.4 billion (7%). The remaining $1.0 billion (3%) was spent by voluntary health associations, foundations, and corporations through worksite health promotion programs.

Of the total prevention-related spending in 1988, $11.6 billion (35%) was spent on preventive health services, $9.8 billion (30%) on health protection, and $7.8 billion (24%) on health promotion. The remaining $3.7 billion (11%) of prevention spending could not be categorized, often because the spending overlapped multiple categories.

To estimate the proportion spent on prevention within the NHA categories, the study identified prevention-related goods and services using the same categories and sources of data as the NHA. In 1988, national health expenditures accounted for $539.9 billion (11% of the GNP) (4); of the total national health expenditures within all categories included in the NHA, $18.4 billion (3%) was spent on prevention.

Reported by: R Brown, MS, J Corea, B Luce, PhD, Battelle, Medical Technology and Policy Research Center, Arlington, Virginia; A Elixhauser, PhD, Agency for Health Care Policy and Research; S Sheingold, PhD, Health Care Financing Administration. Office of Program Planning and Evaluation, Office of the Director, CDC.

Editorial Note

Editorial Note: This study suggests that approximately 3% of health-care expenditures in the United States are allocated to prevention. The accuracy of this estimate, however, is affected by the accuracy of the original data sources and the completeness of data collection. Because of the accountability required for government spending, only spending from private and insurance sources -- which constitute one third of spending on prevention -- are likely to be substantially underestimated. However, even if spending from private and insurance funds had been underestimated by 50%, total spending on prevention would not exceed 5% of expenditures.

Increasing concern about the influence of estimates of health-care effectiveness on policy decisions may require periodic reviews of health information systems. To more accurately characterize the cost and the value of preventive services in the United States, CDC has initiated a multifaceted assessment of the effectiveness of selected preventive measures and strategies (5,6). In addition, the Medical Treatment Effectiveness Program of the Agency for Health Care Policy and Research has instituted efforts to improve the effectiveness and appropriateness of clinical practice, including preventive services (7).

More precise information on the benefits of prevention services should assist legislators, health-care organizations, public health agencies, and other decision makers in developing strategies to address fundamental concerns, such as access to health care, increasing health-care costs, and the changing health-care needs of an aging population (5,6). Strategies to increase and optimize the application of national prevention resources should be designed to 1) increase disease and injury prevention awareness and to promote healthy behaviors; 2) change the social and physical environment to eliminate exposures that can cause disease and injury; and 3) provide counseling and screening in clinical settings.


  1. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

  2. Brown R, Elixhauser A, Corea J, Luce B, Sheingold S. National expenditures for health promotion and disease prevention activities in the United States. Washington, DC: Battelle; Medical Technology Assessment and Policy Research Center, 1991; publication no. BHARC-013/91-019.

  3. Office of National Cost Estimates. Revision to the national health accounts and methodology. Health Care Financing Review 1990;11:42-54.

  4. Office of National Cost Estimates. National health expenditures, 1988. Health Care Financing Review 1990;11:1-41.

  5. CDC. Public health focus: effectiveness of disease and injury prevention. MMWR 1992;41:265-6.

  6. CDC. A framework for assessing the effectiveness of disease and injury prevention. MMWR 1992;41(no. RR-3). 7.Agency for Health Care Policy and Research. Medical treatment effectiveness research. In: AHCPR program note. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, March 1990.

    • The NHA includes health services and supplies; the type of product consumed or the type of facility providing the service determines whether it is included in the NHA. The NHA is categorized into personal health care, government public health activities, program administration, and research and construction. The estimates for these categories are based on secondary data sources that include the federal budget, Bureau of the Census survey of new construction, Consumer Expenditure Survey, nursing home surveys, trade associations, and the Bureau of the Census. The NHA excludes certain prevention programs (e.g., environmental health, sewer and water systems, and some social programs that have a health component). The national health expenditures represent the combined value of these goods and services during a year. ** The most recent year for which data from state health agencies were available that included estimates of the proportion devoted to prevention was 1984, which were applied to total expenditures in 1988.

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