Health is infrastructure, and infrastructure is health

When most people think about infrastructure, what comes to mind is using public dollars to repair collapsing bridges, ensure reliable electrical power, and repave potholes. President Joe Biden is betting that he can persuade the public and hesitant politicians that infrastructure is much more than roads, power, and bridges and that investment in the environment, clean energy, education, and health care must also be part of creating an infrastructure for a strong economy and a healthy and prosperous people. The next stage of his presidency will largely be defined by his success or failure in advancing this understanding.

President Biden's $2-trillion infrastructure proposal, which he calls the American Jobs Plan, includes funding for roads, airports, bridges, and other conventional public works projects, but also hundreds of billions to bring broadband internet access to all communities; expand access to long-term care services, including home-based alternatives to nursing homes, and increase pay and benefits for workers providing such services; eliminate all lead pipes and service lines; upgrade Veterans Affairs (VA) hospitals; promote building and charging stations for all-electric vehicles; safeguard people, many of whom are low-income and people of color, from flooding and other adverse events due to climate change; and “restore nature-based infrastructure—our lands, forests, wetlands, watersheds, and coastal and ocean resources” and other “green” investments. A fact sheet about the program is online.

A separate but related proposal, which the president calls the American Families Plan, calls for billions to be spent on low-cost or free child care, two years of tuition-free community college, universal and free preschool, 12 weeks of paid family and medical leave, expanded tax credits for low-income families with children, and continuation of enhanced tax credits to make health care coverage affordable, among other proposals. Another fact sheet is available online.

Republican members of Congress have reacted to the president's proposals by arguing that they stretch the definition of infrastructure well beyond its traditional meaning of roads and bridges for what they characterize as a “liberal wish list.” Some centrist GOP senators have countered with a much narrower and limited transportation-focused proposal.

The debate over what belongs in infrastructure is not helped by the dictionary. Merriam-Webster defines infrastructure as “1: the system of public works of a country, state, or region. Also: the resources (such as personnel, buildings, or equipment) required for an activity. 2: the underlying foundation or basic framework (as of a system or organization).” This leaves a lot of room for argument about what works should be funded by public dollars, which activities are required and should be given resources, and what should count as being foundational to the success of a particular system and worthy of public investment. How much to spend and on what is a political and policy decision that has to be made, not a semantic one.

For health and health care, though, it seems evident that health is infrastructure, and infrastructure is health. Children who are exposed to lead pipes, many of whom are poorer and people of color, will be less healthy throughout their lifetimes. Living in an area without broadband access means not having the tools to access needed services, like signing up for the COVID-19 and other vaccines; getting a telehealth consultation with your physician or easily scheduling an in-person visit; accessing your health information; receiving preventive health care reminders from your doctor; signing up for coverage from the Affordable Care Act; comparing health care prices for different clinicians; and ordering healthful food and needed medications online.

Warehousing an aging population in underfunded nursing homes with underpaid workers when they might be better cared for at home leads to poorer outcomes, as was seen with the high COVID-19 mortality rate in congregate care facilities. Climate change is directly contributing to more respiratory diseases, insect-borne infectious diseases, heat-exposure illnesses, and flooding and housing displacement. “Educational attainment is often linked to health status and the role of education as a social determinant of health is established throughout the literature,” ACP noted in a recent policy paper, “Understanding and Addressing Disparities and Discrimination in Education and in the Physician Workforce.”

One can't have a healthy economy with unhealthy people.

How much of these issues will be addressed in a final “infrastructure” bill or other legislation that can pass both the House and Senate will not be decided for many more weeks, with a lot of negotiating, posturing, and messaging still to happen. Yet from ACP's perspective, so much of health and health care depends on investing resources to improve education and the environment, provide access to paid family and medical leave, address social drivers of health and health care disparities, upgrade VA and other hospitals, and make coverage affordable, no matter what you want to call it.