Discussion Post

Public Health and Policy

Learning Objectives

By the end of this chapter, you should be able to:

1. Explain the public health system in the United States at its various geographic levels.

2. Discuss the role of the public health system in relation to the private healthcare system.

3. Critically analyze current public health policy issues.

4. Describe the processes involved in implementing public health policy.

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Role and Responsibilities of the U.S. Public Health System Chapter 8

Access to affordable and high-quality healthcare is not the only determinant of a healthy life. Safe prescription drugs, clean drinking water, and the assurance that your favorite pizzeria fol- lows sanitary food preparation guidelines are not the responsibility of the healthcare system. Rather, the public health system is responsible for the health of the U.S. population and the many diverse communities that it includes. Individuals do not live in isolation, but rather are parts of a larger society. Therefore, the poor health of one individual affects the larger whole. For example, the promotion of healthy lifestyles now falls in the domain of employers, health plans, and individuals, as well as national, state, and local health authorities. Like their publicly funded counterparts, private constituents are also concerned with and affected by the high healthcare costs associated with unhealthy lifestyles.

A public health system, comprised of diverse stakeholders, is responsible for the promotion of healthy behaviors in order to prevent and reduce disease. This includes preventive health, such as immunizations and healthy eating, as well as the surveillance and quarantine of contagious diseases. This chapter examines the various components of a public health system and the rela- tionships and challenges of public health with the healthcare system. It also highlights how the public health system forms the foundation of health policy.

The chapter pays particular attention to how public health systems exist at different geographic levels—international, national, and local. For example, at the international level is the World Health Organization (WHO), the public health division of the United Nations. In 1948, WHO defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (Preamble to the Constitution of the World Health Organization, 1948, para. 2). This definition is still used to guide public health initiatives at the global, national, and local levels. This chapter uses this definition and analyzes how modern public health systems work toward maintaining and supporting the health of society.

8.1 Role and Responsibilities of the U.S. Public Health System

Public health is not a new concept. Even the earliest of civilizations recognized the importance of clean water, food, and sanitation. Biblical dietary restrictions, such as avoiding pork and shellfish, are based on an understanding of disease (Harris, 1985).

In the 1500s, the bubonic plague, malaria, and smallpox were responsible for the deaths of thou- sands in Europe, spreading to the New World in the 1700s. John Lind’s discovery of the cause of scurvy in 1753 and Edward Jenner’s development of the smallpox vaccination in 1796, along with other innovations in medicine, paved the way for health reforms and the establishment of public health institutions.

Three macro-level (large in scale or scope) processes can be attributed to the increasing impor- tance of public health in modern times:

1. Industrialization changed an agricultural economy to one based on industry, exposing humans to new toxins and pollution that are largely responsible for the existence of many respiratory diseases. (See the discussion of cancer clusters later in this section.)

2. Urbanization, or the mass movement of people from rural to urban areas, has been linked to the spread of disease. As populations became increasingly urbanized and people began to live physically closer to one another, the spread of disease increased.

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In 1849, Dr. John Snow traced cholera to infected drinking water. The notion that disease could be waterborne was remarkable for that time. This discovery was followed by Louis Pasteur’s germ theory in the mid-19th century, which postulated that microscopic organ- isms, such as bacteria and viruses seen only through a microscope, could invade a human and cause disease (Dove, 2013). It was equally significant that these microorganisms, known as pathogens, were contagious. This discovery led to a new category of medicine known as infectious diseases. (See the feature box about HIV/AIDS.)

3. Globalization is the most recent, macro-level process related to public health. It is defined as the increasingly connected nature of societies across the globe, facilitated through the development and use of technology. Public health officials can use communication technolo- gies to educate populations and contain disease breakouts, as well as to facilitate cooperation between countries when epidemics occur. (See the feature box about SARS.) On the other hand, increased air travel allows diseases to spread rapidly, bringing unheard of maladies to faraway lands. In addition, globalization has brought cheap processed foods to new corners of the world, replacing traditional diets with less healthy versions. This has led to an increase in noncommunicable diseases, or noninfectious behavior-related diseases such as obesity, diabetes, and hypertension.

The American Public Health Association, founded in 1872, has been at the forefront of develop- ing policies in response to all three of these macro-level processes.

More generally, public health infrastructures and policies are targeted at three main geographic levels: federal, state, and local.

Federal Government

The federal government plays a unique role in the public health system. Its primary task is to make sure that the key infrastructures are in place. This requires that the govern- ment is able to coordinate massive efforts across various agencies and provide the nec- essary funding to implement key initiatives. Together, the private healthcare system and private organizations and charities play an important role in the public health system. Yet they cannot sustain public health needs alone because of the size of the effort and the infrastructure needed to maintain the health of an entire population.

The three primary functions of public health agencies at the federal level are assessment, policy development, and assurance (Centers for Disease Control and Prevention [CDC], 2011a).

Assessment The federal government is responsible for assessment—the systematic understanding of a popula- tion’s community health needs. Collecting health statistics, such as infant mortality, and track- ing them over time are essential tasks to determine a community’s health needs. Assessment

Bill Branson/National Cancer Institute/Science Faction/SuperStock

▲▲ The Public Health Cigarette Smoking Act (1970) was a result of support from key stakeholders.

Role and Responsibilities of the U.S. Public Health System Chapter 8

also involves the establishment of oversight agencies to monitor health hazards at the commu- nity level, such as departments that focus exclusively on the inspection of restaurants. Other government assessment efforts include the analysis of industrial and environmental conditions that might contribute to health problems. For example, government agencies regularly test water sources for lead contamination.

Policy development The federal government is uniquely suited for developing public health policy because of its legis- lative role and collaboration with other healthcare organizations, such as healthcare professional associations. For example, the American Academy of Pediatrics (AAP), an association of more than 60,000 primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists, reaffirmed its recommendation for exclusive breastfeeding for six months in 2012 (American Academy of Pediatrics, 2012). This policy recommendation was communicated to new mothers through local public health departments and supported financially by the federal government.

Another part of policy development is the establishment of goals, such as Healthy People 2020. Launched by the Department of Health and Human Services (HHS) in 2010, this initiative set national objectives for improving the health of all Americans by 2020. This particular 10-year plan included several new areas, such as the health of the lesbian, gay, bisexual, and transgen- dered (LGBT) population. One specific goal is to address health disparities among LGBT per- sons by expanding domestic partner health insurance coverage (U.S. Department of Health and Human Services [HHS], 2012b).

Perhaps the most tangible aspect of policy development is getting key stakeholders to support the policies and plans being introduced for legislative action, such as the activities around garnering support for the Public Health Cigarette Smoking Act in 1970. This federal law was designed to limit the practice of smoking, which the scientific community had shown to be detrimental to the public’s health. This Act required that cigarette packages display a strong health warning, and it banned cigarette TV and radio ads—a controversial move at the time.

Assurance or implementation Assurance, or implementation, is a natural responsibility for the federal government that is related to its more general executive function. Implementation, in its most basic form, involves the management of financial resources that facilitate putting policy into action, such as building clinics, hiring new public health specialists, or launching campaigns.

Implementation is also contracting programs out to various organizations at both the state and local level. For instance, managed care organization (MCO) contracts have been used in the past to promote children’s health (HHS, 2004). Although implemented at the federal level by the Department of Health and Human Services, it is the states that are in contractual relationships with the MCOs. (See Chapter 3 for further discussion of MCOs.)

Another category of implementation is the evaluation of program outcomes according to specific standards. Evaluation at the federal level is done in concert with assessment at the state and local levels. The Office of the Assistant Secretary for Preparedness and Response (ASPR) developed performance measures used to evaluate “how well the funding of state and local activities achieve these goals and improve the nation’s ability to prepare for and respond to public health emergen- cies” (Public Health Emergency, 2013, para. 1). The evaluations are used to respond to any gaps identified.

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Another often overlooked, but critical, aspect of implementation is informing and educating the public through the dissemination of findings. This takes place not only in scientific journals meant for the purposes of research, but also in forums more accessible to the general public. Media plays an important role in sharing critical findings. For example, a current public health issue is the increasing rate of obesity in the United States. It is no coincidence that the newspapers are filled with stories about the ever-changing dietary and physical exercise guidelines. Although first published in scholarly journals, these recommendations quickly found their way to main- stream media outlets.

Federal Agencies

Public health functions are performed primarily by federal health agencies. Although the various agencies perform these functions, the cabinet-level Department of Health and Human Services (HHS), monitors their activities. The most well-known federal health agencies are the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), the U.S. Food and Drug Administration (FDA), and the Centers for Medicare & Medicaid Services (CMS).

Centers for Disease Control and Prevention (CDC) The Centers for Disease Control and Prevention (CDC) is the government’s primary public health agency. Founded in 1946 to help control malaria, it now works to “prevent and control infectious and chronic diseases, injuries, workplace hazards, disabilities, and environmental health threats” (CDC, 2013b, para. 11). Headquartered in Atlanta, Georgia, this federal agency also conducts research and is usually the first to respond to health emergencies. A public health emergency refers to a declaration made by the federal government with the purpose of releasing essential resources to contain an actual or possible public health crisis.

An example of a public health emergency was the H1N1 virus in 2009, otherwise referred to as swine flu because of the genes in the virus that were similar to influenza viruses that normally occur in pigs (swine) in North America. In July 2009, the World Health Organization declared H1N1 a pandemic (the rapid spread of an infectious disease across a large population), because cases of this subtype of the Influenza A virus were identified in vast locations across the globe, ranging from the United States to Hong Kong. Over the course of a year, H1N1 was responsible for over 18,000 deaths in 214 countries (World Health Organization [WHO], 2009–2010).

In August 2010, WHO declared the pandemic to be over, but it re-emerged in 2013, resulting in deaths in the United States, Venezuela, Mexico, and Spain. It is unlikely to be eradicated because some strains of H1N1 are endemic in humans and pigs—widespread and pervasive among par- ticular people or in a certain area. Public health efforts are made each year to contain this often fatal strain of influenza.

During pandemics, such as the H1N1 virus, communication and cooperation between WHO and the CDC become critical. Even in the absence of a pandemic, the CDC provides technical exper- tise, as well as financial support, to WHO (CDC, 2010). The CDC shares both programmatic and policy guidance with WHO in the following areas: blood safety, injection safety, counseling and testing, male circumcision, strategic information, prevention of mother-to-child transmission (PMTCT), TB and HIV, and laboratory capacity building (CDC, 2010).

The citizens of every country have unique health concerns that are addressed by their public health systems. The World Health Organization supports the public health systems of member

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countries of the United Nations through its various programs and initiatives. For example, in Afghanistan one of the leading public health issues in 2014 was the spread of vector-borne dis- eases—illnesses caused by blood sucking insects such as mosquitoes, fleas, and ticks (WHO, 2014c). Whereas in the United States, WHO’s efforts primarily revolve around noncommuni- cable diseases (WHO, 2011).

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SARS

In 2003 the World Health Organization declared Severe Acute Respiratory Syndrome (SARS) a seri- ous global threat. Believed to have started in China, the SARS virus is a respiratory disease that can be fatal. The ease of international travel posed a serious risk for the potential and rapid spread of SARS. However, the United States prevented SARS from becoming an epidemic through the use of two primary public health containment strategies: surveillance and quarantine.

Surveillance is defined as “the continuous, systematic collection, analysis and interpretation of health-related data needed for the planning, implementation, and evaluation of public health practice” (WHO, 2014b, para. 1). For SARS, this included keeping track of the number of people infected and their locations. The CDC worked closely with the Council of State and Territorial Epidemiologists to identify infected individuals (CDC, 2008).

Surveillance also involves communication among national, state, and local health agencies. In the case of infectious diseases, surveillance focuses on a limited list of diseases that spread easily through intimate or close contact, referred to as reportable diseases. Although any healthcare professional can report these diseases, physicians and medical laboratories are the most likely to identify reportable diseases and report them to a local health department. In addition to reportable diseases, states are required to report cases of diseases that appear on the national list of notifi- able diseases. At the national level, these reports are analyzed and posted on the Internet. This rapid dissemination of information allows health officers across the country to be aware of potential diseases in their area.

One of the latest developments in the area of surveillance is the use of electronic health records (EHRs) to more efficiently anticipate and detect disease outbreaks. EHRs (see full discussion in Chapter 10) were developed to increase both the efficacy and efficiency of patient care. Their use in early detection surveillance efforts is known as syndromic surveillance. However, this practice does not monitor for specific disease syndromes, but rather surrogate data sources (e.g., over-the- counter prescription sales or school absenteeism). Through the use of EHRs or electronic ambulatory care data, public health officials can obtain patient data in real time (Yih et al., 2004). For instance, by tracking the sale of flu medications or emergency room visits of patients with flu-like symptoms, public health officials can anticipate a potential flu epidemic.

The name “syndromic surveillance” has led to confusion about what syndromic surveillance actu- ally monitors (Henning, 2004). In fact, diverse names have been used to describe public health surveillance systems with the same primary goal of early outbreak detection: early warning systems, prodrome surveillance, outbreak detection systems, information system-based sentinel surveillance, biosurveillance systems, health indicator surveillance, and symptom-based surveillance. Syndromic surveillance is the term that has persisted over time (Henning, 2004).

Syndromic surveillance, however, is not without its limitations. In the case of the 2009 H1N1 out- break, it was found that syndromic data was helpful in monitoring virus activity and measuring the

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National Institutes of Health (NIH) The National Institutes of Health (NIH) is a primary example of a government agency created to support and advance public health. Its tagline, “the nation’s medical research agency—support- ing scientific studies that turn discovery into health,” exemplifies its mission. Headquartered in Bethesda, Maryland, the NIH is the federal government’s premier medical research facility, hailed with discovering and funding key medical advances. The latest figures show that the NIH supports almost $30 billion worth of research each year—an amount largely funded by federal taxes (National Institutes of Health [NIH], 2014b).

The NIH also provides critical training to scientists and physicians in its 27 separate institutes and centers. One of these 27 is the NIH’s Intramural Research Program (IRP). This program has been credited with many discoveries relevant to public health, including the development of fluoride to prevent tooth decay, the prescription drug Lithium to treat bipolar disorder, and several vaccines (such as those for hepatitis and human papillomavirus [HPV]). Current research is devoted to identifying the genetic risk of Alzheimer’s disease, understanding deafness, and the development of a nonaddictive form of cocaine to be used in substance abuse treatment (NIH, n.d.-c).

The NIH also supports research that translates directly into advances in patient care and treat- ment. These research initiatives primarily fall in their Bench-to-Bedside (B2B) Program (NIH, 2014a). This program funds translational research, which aims to translate basic scientific find- ings into therapeutic interventions for patients. The research categories most often represented in this program are “AIDS, rare diseases, behavioral and social sciences, minority health and health disparities, women’s health, rare diseases drug development, pharmacogenomics, and general” (NIH, 2014a, para. 4). Increasingly, translational research is being used in the treatment of can- cer (Goldblatt & Lee, 2010). One specific focus is on developing individualized therapies, since response to therapy differs based on the individual (Goldblatt & Lee, 2010). Another challenge is how to manage the toxicity of many cancer treatments with the goal of improving overall patient care.

impact on the healthcare system, but it did not serve its intended purpose of early outbreak detec- tion (Chu et al., 2012). Furthermore, the study showed that the data produced had a limited impact on decisions that involved the operation of immunization clinics, school closures, and information letters sent home with school children, or recommendations to healthcare providers (Chu et al., 2012). Regardless, this type of surveillance system is increasingly being used as electronic forms of patient data continue to gain prevalence in the U.S. healthcare system (Samoff, Fangman, Ising, Deyneka, & Waller, 2013).

According to the CDC, quarantine is a strategy used to “separate and restrict the movement of well persons who may have been exposed to a communicable disease to see if they become ill” (CDC, 2014, para. 1). In the case of SARS, states had the authority to declare and enforce quaran- tine within their borders. The CDC’s Division of Global Migration and Quarantine is also empowered to detain, medically examine, or conditionally release persons suspected of carrying certain com- municable diseases. This authority was used at international airports from Asia to North America to identify individuals who might have been exposed to the virus. Although reports are mixed about the success of quarantine in the case of SARS (Hsieh et al., 2005; Schabas, 2004), it remains a strategy used to mitigate the spread of contagious diseases. In the end, the SARS outbreak taught public health agencies around the world how to successfully prevent and manage an epidemic on a global scale.

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Food and Drug Administration (FDA) The Food and Drug Administration (FDA) is the federal agency responsible for assuring the pub- lic that food and drugs consumed in the United States are safe. Originally part of the Department of Agriculture, the FDA’s regulatory functions began in 1906 with the passage of the Pure Food and Drugs Act. The Federal Food, Drug, and Cosmetic Act of 1938 further increased the FDA’s authority over the marketing of new drugs. All new drugs were mandated to have a pre-market review to ensure their safety, which led to designating some drugs as “prescription only.”

The FDA’s scope of authority continued to expand, particularly in the development of new technologies. Today, it is responsible for the regulation of food, drugs, and medi- cal devices; animal feed and drugs; cosmet- ics; and any radiation-emitting products. In addition, it is tasked with regulating the advertising and labeling of these products.

When President Obama signed into law the Family Smoking Prevention and Tobacco Control Act in 2009, the FDA was given comprehensive authority to regulate the tobacco industry, a drug that was histori- cally exempt from this type of scrutiny by a federal agency. The FDA now regulates the manufacture, marketing, and sale of all tobacco products. Under the authority of

the FDA, the law “recognizes that virtually all new users of tobacco products are under 18—the minimum legal age to purchase these products. Many new users will become addicted before they are old enough to understand the risks and ultimately will die too young of tobacco-related diseases” (U. S. Food and Drug Administration, 2013b, para. 2).

The Centers for Medicare & Medicaid Services (CMS) The federal agency responsible for providing access to healthcare for the elderly, the poor, and the permanently disabled is the Centers for Medicare & Medicaid Services (CMS). Originally known as the Health Care Financing Administration, this federal agency, under the HHS, was formed in 1977 to facilitate Medicare and Medicaid programs. (See Chapter 3 for further discussion.) More recently under the Affordable Care Act (ACA), CMS was tasked with developing new programs.

CMS is also a key participant in the government’s public health system, given its charge to ensure healthcare access for underprivileged populations and communities. As such, it is at the forefront of public health policy. The increasingly larger aging population is a key public health issue, and CMS is at the center of policy initiatives aimed to manage the healthcare needs of this growing population, particularly the provision of Medicare.

State Government

Although the federal government is often both legislatively and financially best suited to direct the country’s public health system, the U.S. Constitution gives individual states the responsibil- ity to safeguard the health of their citizens. In fact, the individual who directs the state’s public

Toby Talbot/Associated Press

▲▲ One of the FDA’s many responsibilities is the regulation of advertising and labeling of food products.

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health department has the right to carry out public health laws and to declare a public health state of emergency.

In 1855, Massachusetts was the first state to establish a department of public health. Today, there are, on average, 28 state agencies with health roles in each state. These agencies work in collabora- tion with the federal government in varying degrees. These various state agencies have different functions, including:

• Licensing • Inspecting • Collecting data • Investigating the incidence and distribution of disease • Managing communicable diseases • Formulating health policy • Providing community health education

Licensing of healthcare professionals and facilities Each state is responsible for setting educational and performance standards as prerequisites to issuing licenses to healthcare professionals. Physicians, dentists, chiropractors, pharmacists, optometrists, nurses, veterinarians, and other professionals must obtain proper state licenses in order to practice within a given state. When professionals who were formally licensed in other states move across state borders, they must obtain new licenses to practice.

A related function of state health agencies is the inspection and licensing of healthcare facilities. This includes hospitals, nursing homes, and rehabilitation facilities. State officials are charged with making sure that these facilities meet state-specified standards. The scope of these agency inspections is broad and can range from checking whether proper staff–patient ratios are being upheld to whether medical records are being kept safe and confidential. Under the ACA, failure of a facility to comply with these standards is grounds for revoking its license or penalizing it financially (i.e., denying Medicare reimbursements).

C A S E

HIPAA: Easy to Follow, Easy to Violate

The Health Insurance Portability and Accountability Act (HIPAA) of 1996, enacted on August 21, 1996, appears to be an easy law to follow. Basically, it sets national standards for protecting personal health information. More commonly known as The Privacy Rule, this law addresses the actions that need to be taken in order to assure that unauthorized personnel do not have access to individuals’ personal health records.

The Privacy Rule applies to health plans, healthcare clearinghouses, and any healthcare provider who transmits health information in electronic form. What is protected is known as “individually identifiable health information,” which includes all demographic information on the individual as well as healthcare plans, treatments, and payments. If the release of any of this information is needed for whatever purpose, written authorization from the individual regarding specific terms and conditions of its use is required by this law.

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While the law seems clear, there are significant HIPAA breaches every year which result in losses that extend into the billions. According to a study by the Ponemon Institute on privacy and data breaches, the cost for such violations could be as high as $7 billion annually. Here are a few other statistics discovered by the Ponemon Institute (2012):

• 94% of healthcare organizations have experienced at least one data breach in the last 24 months.

• The average economic impact of a data breach over the past two years for health care organiza- tions was $2.4 million.

• The top three causes for a data breach: lost or stolen computers and/or devices; employee mis- takes; and third-party issues (other causes included criminal attacks, technical glitches, and mali- cious insiders).

• More than half of the healthcare organizations have little or no confidence that their organiza- tion could detect a data breach.

• 81% of employees are allowed to obtain secure information via their personal mobile devices– yet most of them are not secure.

• The data most susceptible to theft or loss is patient billing information and employee records. • Only 16% of healthcare organizations perform an annual or periodic privacy risk assessment.

According to the Ponemon Institute (2011), it’s far more expensive to be noncompliant than com- pliant regarding privacy and HIPAA issues. Costs for lawsuits and breaches are often never fully recovered. The Ponemon Institute (2011) found that the average cost of noncompliance exceeds $9 million per company, or approximately $820 per employee. Compliance actions cost just under $7 million, or an average of approximately $635 per employee, depending on the size of the company.

Case in Point: Isaac Earl Smith and Annetra Poole-Moore

In 2011, the U.S. Attorney General’s Office of Northern District of Alabama sentenced Isaac Earl Smith to six years in prison for healthcare fraud, HIPAA violations, and aggravated identity theft. Also sentenced was Smith’s partner, Annetra Poole-Moore, who received four years in prison on the same charges.

Between September 2008 and April 2009, Smith and Poole-Moore accessed the personal informa- tion of individuals who had flexible spending accounts through United Healthcare, Inc., and who also had prescription drug coverage through the Federal Employees Health Benefit Plan (FEHBP). The two then created counterfeit prescriptions for controlled substances, filled them, and resold them for profit. This left the Federal Employees Health Benefit Plan (FEHBP) to foot the bill—result- ing in a $72,746 loss.

The scheme seemed foolproof. As a claims representative for United Healthcare, Inc., Poole-Moore had access to personal health plan information. She pulled individual prescription drug records from the company’s electronic database—and passed that information to her partner, Smith. He created hard-copy prescriptions for controlled substances and filled them at various pharmacies. He then sold the prescription drugs illegally. Using the stolen identities, Poole-Moore and Smith billed the FEHBP for the drugs. The number of accounts breached was not released.

While the information in the court records did not indicate specifically how the perpetrators were caught, it appears that United Healthcare may have prompted an investigation based on iden- tity theft concerns of its clients, as well as an influx of reimbursements for controlled substances. Multiple agencies were involved in the investigation, including the U.S. Postal Inspection Service, the Food and Drug Administration Office of Criminal Investigations, the U.S. Secret Service, the Office of Personnel Management, and the Montevallo (Alabama) Police Department (U.S. Attorney’s Office, 2011). In addition to prison sentences, both Poole-Moore and Smith were ordered to repay the FEHBP for the cost of the stolen drugs and to pay another $72,746 in court costs.

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Collection of vital health statistics The collection of vital health statistics of a state’s population is another function of the state health agencies, including information about the deaths, births, marriages, health, and diseases in a given year. Analysis of these statistics is used for funding purposes, as well as for planning effective public health initiatives. For instance, if a state observes a rise in birth rates over a given period of time, then it might request additional funding from the federal government for assis- tance programs such as Women, Infants, and Children (WIC). State health agencies also look for patterns and changes in the rate of disease in order to prepare for interventions and treatments.

Investigation of incidence and distribution of disease Investigation of the incidence and distribution of disease allows public health agencies at the state level to employ epidemiologists to investigate the origin of diseases discovered in the population. Epidemiology is a field of science concerned with the incidence, distribution, and control of disease. Although the CDC is responsible at the national level, state public health agencies deter- mine which diseases to report annually in order to have estimated incidence data. The individual state data is compiled into a weekly report called the Morbidity and Mortality Weekly Report (MMWR) and made available to the public on the CDC’s website (http://www.cdc.gov/mmwr/).

This data is also used to analyze the distribution of disease. If a particular disease is significantly more prevalent in one particular state or neighborhood, then further investigation is needed. Similarly, if a disease presents more commonly in one segment of society, epidemiologists exam- ine whether there is a genetic determinant or if there is a social cause to the disease.

The analysis of disease distribution data at the state level has identified so-called “cancer clusters” throughout the United States. A cancer cluster is defined as “a greater-than-expected number of cancer cases that occurs within a group of people in a geographic area over a period of time” (CDC, 2012, para. 3). The CDC has set specific criteria that a cluster must meet for a state agency to launch a full investigation. Clusters of other diseases also have been identified, such as the high incidence of birth defects, miscarriages, and certain respiratory diseases. As of 2011, 42 disease clusters in 13 states were identified by the National Resources Defense Council (Miriello & Pearson, 2011; Natural Resources Defense Council, 2011).

Development of health policy Developing health policy is a function of state public health agencies. The agencies are similar to those at the federal level and are uniquely positioned to formulate health policy and legisla- tion. At the state level, this is most often achieved through intentional cooperation between state legislators and community boards of health and health agencies. For example, in 2012 California became the first state to pass public health laws requiring smog checks for clean air, as well as bike helmet laws. That same year, over 760 new laws went into effect, including the prohibition of

Critical Thinking Questions

1. Is it possible to fully eliminate security breaches? Examine the steps that system developers and facility IT directors should take to achieve this goal.

2. As stated above, more than half of the healthcare organizations have little or no confidence that their organization could detect a data breach. How can an organization increase that confidence?

3. Examine the appropriateness of HIPAA. Has it resulted in improvements in privacy and confiden- tiality or has it caused more problems and challenges? Explain your response.

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importing shark fins, the requirement for student athletes to have medical clearance after suffer- ing a head injury, and the ban of tanning booths for teenagers (M. Park, 2012).

Community health education Public health agencies provide the community with adequate health education, so that citizens are aware of the public health laws and the reasons behind them. Additionally, these agencies strive to reduce the spread of disease through education, which will, in turn, reduce the demands on the state’s public health system. For example, Tennessee’s department of public health pro- vides community health education programs, such as the Community Prevention Initiative (CPI) for Children. This program was developed to reduce the chances of a child becoming involved in risky behaviors, such as alcohol, drugs, violence, and teen pregnancy (Tennessee Department of Health, 2013). CPI offers educational programs for children and their families both in and out of school, as well as parent education.

Local Health Departments

It is unlikely that most citizens will encounter federal or state public health officials. Instead, pub- lic health services are generally provided through local public health agencies. The United States has over 3,000 local public health agencies with tremendous geographic variation in the types of services offered. Most local agencies provide food safety inspection, sanitation services, sewage disposal, pest control, drinking water purification, restaurant licensing and inspection, disease surveillance and immunization, and public health education. In addition, most local agencies offer personal health services. These are usually related to well-baby care, vaccinations, infectious diseases, and outpatient mental healthcare.

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HIV/AIDS

The prevention of sexually transmitted diseases (STDs), such as chlamydia, gonorrhea, and syphilis, has historically been a priority for local public health agencies. Beginning in the 1980s, one particu- lar STD took the center stage of public health concerns: HIV/AIDS. HIV (Human Immunodeficiency Virus) is the virus that causes AIDS (Acquired Immunodeficiency Syndrome). Because HIV and AIDS are infectious diseases—health conditions that can be spread from one person to another—they are of great concern to public health officials.

With advances in medicine, HIV is no longer a death sentence. In fact, recently a baby born with HIV was cured through treatment at 30 hours of life (Pollack & McNeil, 2013). A “functional” cure (i.e., when a disease is undetectable through standard methods after treatment) was also observed in 14 adults with HIV in France (Smith, 2013). Similar to the case of the infant, the successful out- come of the adults was attributed to both early diagnosis and treatment (Smith, 2013).

Beyond widespread education campaigns about how the diseases are spread, local public health departments have developed various programs to serve this vulnerable population. For instance, several older studies found that people infected with HIV/AIDS have different outcomes based on whether they are treated by a primary care doctor or a specialist (Chu, Umanski, Blank, Grossberg, & Selwyn, 2010; Landon et al., 2003). Those under the care of a generalist are more likely to be hospitalized compared to those treated by a doctor with training in AIDS ambulatory care (Holmes, 1997). Based on these findings, community clinics were established to specifically meet the health needs of HIV/AIDS patients.

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In order to provide critical healthcare to underserved regions in the United States, the federal government authorized the establishment of community health centers beginning in the 1960s. By 2010, more than 1,100 of these centers were funded by the Bureau of Primary Healthcare (BPHC) within the HHS (Bureau of Primary Healthcare, 2010).

These community health centers are legally mandated to be located in areas inhabited by a sig- nificant medically underserved population and to provide services to any person in need of care regardless of insurance or the ability to pay (HHS, 2014). Given the populations these health cen- ters serve, the centers function as de facto safety nets for those unable to afford healthcare, as well as noncitizens who do not have access to health insurance in the United States. The public health system is responsible for ensuring that these populations have access to adequate healthcare.

Similar to the motivation for the ACA, these clinics were established to address health disparities in health services. The range of services they provide is quite limited, but largely involve family- oriented healthcare, including medical, dental, mental health, and substance abuse treatment. According to BPHC data (2010), most patients visiting these clinics have incomes less than 200% of the federal poverty rate, and many are homeless.

In addition to community health centers, federal funding also supports migrant health cen- ters, which were established to serve transient farm workers in agricultural communities. Similarly, rural health centers were established to serve isolated communities that are medically underserved.

8.2 Relationship Between Public Health Systems and Private Medicine

Unlike public health, private healthcare is concerned with providing care to the individual. One example that illustrates the difference between these health systems is their responses to the polio outbreak in the early and mid-20th century. Doctors, as the main representative of the private health system, treated patients who had contracted polio. In contrast, it was the duty of the public health system to close public places, such as swimming pools, that were thought to be potential sites of disease transmission. The public health system also established the National Foundation for Infantile Paralysis (now the March of Dimes) and other research insti- tutions to begin the long search for a cure.

Private healthcare providers (doctors, nurses, hospitals, nursing homes, etc.) play a crucial role in public health. The private sector’s cooperation and collaboration is essential for the public health system to flourish. For example, private doctors often screen for diseases and then report the information to local and state departments of health. Hospitals are common sites for patient education. Even pharmacies provide preventive healthcare, offering education and immunizations.

Mario Ragma/Hemera/Thinkstock

▲▲ Universal vaccinations require the coordination of public and private health systems.

What Is Health Policy? Chapter 8

The public system’s commitment to the idea of social justice distinguishes it from the private system. According to the principle of social justice, healthcare should ideally be divided equally, and society is responsible to make sure this happens. This ideal is not congruent with capitalism, which has become a driving force of private medicine. Analysts have concluded that an inherent incompatibility exists between public health and private healthcare. Theoretically the two sys- tems should have the same goal: to improve and maintain the health of a society (Kukaswadia, 2013). In reality, the public health system and the private health system work as partners; for example, they help the public prepare for flu season each year (see Under the Microscope: A Plan for Containing a Hypothetical Pandemic).

U N D E R T H E M I C R O S C O P E

A Plan for Containing a Hypothetical Pandemic

Every February, WHO, the global public health agency, announces the strains for the winter flu (i.e., influenza). Private vaccine manufacturers then grow these strains in fertilized chicken eggs, and vac- cines are produced. The flu vaccinations are made available to the public beginning in September each year.

At the federal level, the CDC recommends that everyone over the age of six months get a flu shot. This recommendation is passed down to healthcare providers in both the public and private health systems. States and then counties are given a certain number of vaccines based on the area’s population size and anticipated compliance. Healthcare providers, including pharmacies, enact this recommendation at the local level. Universal vaccination aims to avoid a pandemic. However, state public health departments actively prepare for the possibility of seasonal flu becoming a pandemic, which requires even more intimate coordination between the public and private health systems.

Under the direction of the HHS, the federal government formulated a plan for containing a hypo- thetical pandemic. Guidelines prepared by a federal interagency working group included input from the public and other stakeholders, including businesses and community organizations. In the early stages of a pandemic, it is feared that vaccination production will not be rapid enough to meet the needs of the entire population. This means that state and local public health agencies will have to allocate the vaccine to the most vulnerable populations.

However, to avoid the need to ration the vaccine, the federal government has invested significant funding to develop new technologies that allow for the production of enough influenza vaccine for every person in the United States who wants to be vaccinated within six months of a pandemic declaration.

8.3 What Is Health Policy? Using the flu example in the previous section, the decision about individuals who should receive the flu vaccine in the case of a shortage is part of a health policy. Aimed to protect and maintain the health of the population, such policies consist of a combination of laws and regulations that underlie the health mission of a government. In the United States, the legislative, judicial, and executive branches of government make decisions on policies that address the health needs of communities and individuals. These decisions are based on the expert guidance from state and local public health departments, nonprofit organizations, academics, and healthcare profession- als, as well as key stakeholders at the community level.

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It is important to note that critical health policy issues are fluid and respond to the changing health needs of the population. For instance, in the 1960s health policies were introduced to improve the health outcomes of low-income pregnant or postpartum women, their infants, and children up to the age of five. The WIC program originally began as a two-year pilot program in 1972 under an amendment to the Child Nutrition Act of 1966, and was made permanent in 1974. Its mission is to provide supplemental food, nutrition education, and healthcare referrals to this disadvantaged population. However, with the rise of obesity, WIC has the additional task of promoting healthy lifestyles, including nutrition and physical exercise.

E T H I C S P R E S C R I P T I O N

Obesity and Soda Taxes

Every day there seems to be a new study or report on obesity in the United States. The most recent statistics suggest that two out of three Americans are overweight or obese (Ogden, Carroll, Kit, & Flegal, 2014). These rates among adults and children are so high that obesity is often referred to as an epidemic—a rate of disease incidence in a given population that is significantly higher than what is expected based on the past.

As noted earlier, globalization has been attributed to the rise in noncommunicable diseases on a worldwide scale. In the United States, the rise in obesity has been attributed to a higher consump- tion of fat and sugar and a decreased rate of physical exercise. One of the culprits identified by the public health community is the country’s high consumption of soft drinks, or sodas, a rate well above any other country’s. A recent Gallup poll found that almost half of Americans drink soda every day; young adults consume the most, and soda is the largest source of sugar in the diet of children and teenagers (Saad, 2012). These high rates of consumption have been linked to increased risk of diabetes, obesity, and childhood behavior disorders (Neporent, 2013).

To address this public health issue, several proposals have emerged to levy a tax on sugary bever- ages, which has become known as the “soda tax.” Proposals have been included on several local and state ballots, including New York City; Richmond, California; and the state of Washington. While many of these initiatives have failed, Maryland and Virginia are two of 33 states that levy sales taxes on soda. Maryland taxes soda at a rate of 6%, Virginia at 1.5%. In fact, Virginia is also one of six states to impose a state excise tax on soda in addition to a sales tax.

The “soda tax” has gone global. In 2013, the Mexican Senate passed a one peso tax (approximately $0.08) per liter of soda and a 5% tax on junk food (Cohen, 2013). France also approved a similar tax on sugary drinks in 2012 (Cohen, 2013; France backs tax, 2011).

Social critics of these taxes are concerned that the government is becoming too involved in control- ling what private citizens eat and drink. But the big money for the opposition has come from the American Beverage Association, which represents soda manufacturers such as PepsiCo, Coca-Cola, and Dr. Pepper Snapple Group. The association has spent millions of dollars to defeat soda taxes around the country—nearly $17 million in Washington State alone to rescind that state’s soda tax (Baertlein & Geller, 2012).

Given the size of the country and its diverse health needs, the United States does not have a single cohesive health policy. The ACA most certainly reflected the culmination of recent health policies around issues of access and quality of care, as well as universal health coverage and cost contain- ment. However, health policies reflect other issues as well, including the aging U.S. population.

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To help organize the various health policies, five main forms of health policies are discussed in the following sections:

1. Laws 2. Rules and regulations 3. Operational decisions 4. Judicial decisions 5. Macro policies

Laws. One form of health policy are laws— or rules of conduct or action prescribed or formally recognized as binding or enforced by a controlling authority. Laws can be enacted by any level of government. They also can be referred to as a program. The Medicare program is an example of this form of health policy.

Rules and regulations. Rules and regula- tions provide a guide as to how laws should be implemented. The executive branch or the organizations and agencies responsible for implementing laws generally make this type of policy. Through the federal govern- ment website regulations.gov, the public can read and comment on specific rules

and regulations of the various agencies. For example, a search of CDC rules results in topics as varied as Requirements for Importers of Nonhuman Primates and Specifications for Medical Examinations of Underground Coal Miners. (Regulations.gov, n.d.).

Operational decisions. Operational decisions are made by the executive branch of the govern- ment as a part of the implementation of a law. Generally, these decisions consist of protocols and procedures that follow the implementation of a new law. These decisions tend to be less perma- nent than rules or regulations. An example of an operational decision would be the decision that extended the enrollment in ACA through the state insurance exchanges.

Judicial decisions. Judicial decisions are policies that result from decisions made in the court system. For example, in 2012, the FDA imposed voluntary restraints on nontherapeutic use of antibiotics in livestock production and rejected the judicial decision ordering the full ban of tetra- cycline and penicillin in animal feed (Harris, 2012). Following the judicial decision of a New York District Court judge who ruled in favor of the National Resources Defense Council, Center for Science in the Public Interest, Food Animal Concerns Trust, Union of Concerned Scientists, and Public Citizen, the FDA was ordered to inform drug manufacturers that it intended to prohibit the use of penicillin and tetracycline to promote growth in animals.

Macro policies. The broadest form of health policy is the macro policy. This represents an expansive policy that helps shape a society’s pursuit of health in fundamental ways. A prime example of a macro policy is the FDA’s regulation of the tobacco industry. (See the Food and Drug Administration section for more information about the FDA and the tobacco industry.)

Biosphoto / SuperStock

▲▲ Health policy dictates the use of antibiotics in livestock pro- duction and animal feed.

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The five forms of health policy described previously can be further divided into two main types: regulatory and allocative policies (Longest, 1994).

Regulatory Policies

Regulatory policies are designed to influence the actions, behaviors, and decisions of others to ensure that public objectives are met. In other words, their purpose is to regulate what happens when policies are put into action. The main categories of regulatory policies include: social regu- lations, quality controls, market-entry regulations, rate or price-setting controls, and market- preserving regulations.

Social regulatory policies A social regulation is a type of regulatory policy that is established in order to achieve socially desirable outcomes and to reduce socially undesirable outcomes. Examples of social regula- tions include environmental protection, childhood immunization requirements, and public smoking bans.

E T H I C S P R E S C R I P T I O N

To Immunize or Not to Immunize

The use of vaccines is often referred to as one of the greatest public health success stories. It is undeniable that immunizations have reduced the number of deaths from infectious diseases, such as polio, tuberculosis, and measles. Certain diseases, such as smallpox, no longer exist because of the use of vaccines.

However, despite this success, a debate has emerged as to whether parents should universally immunize their children. The controversy lies in questions of safety and the possible side effects that can result from vaccinations (Chen & Hibbs, 1998; King Heyworth, 2010). Yet the CDC and the American Academy of Pediatrics (AAP) continue to recommend that healthy children get vaccinated against 14 diseases by age 2 followed by boosters at later ages. Although the national immuniza- tion rate has remained stable over the past decade (almost two-thirds of children were up to date), a significant number of parents opt to not vaccinate their children or visit doctors who offer alter- nate vaccination schedules (i.e., the option of spreading out the administration of vaccines instead of following the immunization schedule set by the CDC) (Storrs, 2012).

Public opinion of vaccinations changed dramatically from the “holy grail” of public health to a pos- sible source of harm. In 1998 a group of British gastroenterologists published an article claiming a link between the measles, mumps, and rubella (MMR) combination vaccine and intestinal problems that they believed led to autism (Wakefield et al., 1998). Although the findings of this study have since been retracted and more than seven comprehensive studies refute these findings, the skepti- cism towards vaccinations still exists.

Mandatory vaccination remains controversial because school-aged children are required to have immunizations in order to register for school. All states, except California, require exemptions to be based on either philosophical or religious grounds (CDC, 2011b). California allows an exemp- tion based on the parents’ beliefs, which do not need to be grounded in either religion or ethics. However, some fear that failure to universally immunize children will lead to outbreaks of diseases, such as measles (Brown, 2013).

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Regulatory public health policies to protect consumers Regulatory policies also include those specifically created to protect consumers of healthcare. These policies include the following types of regulations:

• Quality control regulations. Quality control regulations ensure that health service pro- viders adhere to acceptable levels of quality in the services they provide and that producers of health-related products meet safety and efficacy standards. An example of this includes the FDA’s regulation of pharmaceuticals.

• Market-entry regulations. Market-entry regulations focus on licensing of practitioners and organizations. For example, physicians must have certain credentials in order to be licensed to practice. These standards vary by state, but at a minimum, all physicians are required to have completed medical school and a medical residency, and to have passed state board exams. A hospital might require additional provisions for doctors to gain hos- pital privileges.

• Rate or price regulations. Rate or price regulations control the growth of prices for the consumer. For example, the federal government controls the rates of reimbursement to hospitals that participate in the Medicare program.

• Market-preserving regulations. Market-preserving regulations establish and enforce rules of conduct for market participants. For instance, they promote fair competition within the healthcare industry for the benefit of consumers. This was particularly relevant with the creation of state insurance exchanges.

Allocative Policies

Allocative policies are designed to provide benefits to some distinct group or class of individu- als or organizations at the expense of others to ensure that public objectives are met. In general, allocative policies come in the form of subsidies (i.e., income, services, or goods). Some examples include Medicare and Medicaid policies, and federal aid to medical schools. The ACA individual mandate, which offers government subsidies to certain low-income individuals, is a prime exam- ple of an allocative health policy. (See Chapter 3 for more information about health financing and reimbursements.)

Allocative policies can be further divided into distributive and redistributive. Distributive poli- cies spread benefits throughout a given population. In contrast, redistributive policies aim to level the playing field by providing subsidies or offering program eligibility only to a particular segment of the population.

Distributive policies are less controversial than redistributive ones because they benefit every- one. An example of a distributive policy is the NIH funding of medical research. In theory, the outcome of this research will benefit the public good. Redistributive policies are often conten- tious because they are viewed to exclude some groups. Medicaid is one example because only households with a certain income qualify. However, it is a program funded by federal and state taxes—taxes paid by individuals the program does not serve.

8.4 How Health Policy Is Created Regardless of the specific type, health policy is created in the United States through a back-and- forth process. It starts with legislative, public, or private entities setting forth a law or principle. The public responds to these laws or principles. Their reactions spur actions by other sectors.

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Health “policy,” in the end, is constantly in a state of flux—a permanent work in progress that is always being refined and revised.

The introduction of Medicare is an example of health policy in action. Medicare came directly from legislation, and its introduction led to the formulation of additional policies regarding how the United States assists the elderly and permanently disabled with access to healthcare. Years after its introduction, it was found that there were situations in which the elderly were struggling to cover their portion of health costs. This led to the creation of Medigap insurance policies, or supplemental private health insurance, in the 1980s. (See Chapter 3 for more details about Medicare and Medigap insurance.) The ACA further extended and modified Medicare, which demonstrates again the fluidity of U.S. health policy.

Health policy is created through two main processes: the policy cycle and the legislative process.

Policy Cycle

Policy analysts use the framework of a policy cycle as a way to describe the process of how health policies are created and how an issue moves from its initial inception to implementation, evalua- tion, and a new agenda. Table 8.1 illustrates the five stages of the policy cycle and their relation- ship to problem solving.

Table 8.1: The policy cycle

Stage

Phases of problem solving

Description and comments

Agenda-setting Problem recognition How an issue comes to the attention of policymakers. The process is not always rational, and it can often be difficult to see why some issues rise to the top of political agendas, while other, seemingly more important issues, remain unaddressed.

Policy formulation Proposal of solution Decision-makers (governments, health regions, hospitals, care teams, etc.) formulate policy options. Government policymaking usually occurs behind the scenes and is carried out by professional policy analysts.

Decision-making Choice of solution How decision-makers decide what to do—or not do—about an issue.

Policy implementation Putting solution into effect Putting the decisions into effect.

Policy evaluation Monitoring results Examining implementation and outcomes to determine if the policy has been properly imple- mented and if the desired outcomes were achieved.

Source: Adapted from Howlett, M., & Ramesh, M. (1995). Studying public policy: Policy cycles and policy subsystems. Toronto, CAN: Oxford University Press Canada, p. 187.

Stage 1: Agenda-setting. The first stage in the policy cycle is agenda-setting. At this point, there is widespread recognition of a problem by a variety of stakeholders, including community orga- nizations, researchers, and policymakers. Politics are behind the issues that make it to this early stage of the policy cycle and those that do not (Howlett & Ramesh, 1995).

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Stage 2: Policy formulation. After agenda-setting, the next stage of the policy cycle is policy for- mulation. This is the phase during which various proposals and possible solutions are put forth. Options for policies are developed by think tanks (i.e., independent research institutions), gov- ernment agencies, and other decision-makers. This most often is completed behind the scenes, and the public is rarely aware of these early policy blueprints.

Stage 3: Decision-making. The third stage in the policy cycle is decision-making. This occurs when one of the proposals is selected and, in essence, policymakers decide what to do and what not to do.

Stage 4: Policy implementation. The choice for the solution affects the fourth stage of the cycle, policy implementation. The selected proposal is now put into action with hopes of success. More than likely this takes time and involves significant challenges.

Stage 5: Policy evaluation. The final stage of the cycle is policy evaluation, during which results are monitored. At this point in the process, questions are answered, such as whether the policy was implemented properly and whether the desired outcomes were achieved. Changes are made based on these evaluations.

An illustrative example of the policy cycle is the Affordable Care Act. During the agenda-setting stage, it was widely recognized that large numbers of uninsured individuals have both economic and social disadvantages in society. Although this has been the reality for many decades, the political climate brought it to the top of the agenda during President Obama’s first term in office.

During the second stage of the policy cycle, multiple decision-makers put forth healthcare policy options. For example, during the 2009 congressional summer recess, town hall meetings were held in districts across the country to solicit input from the general public on the various proposals.

The third stage of the policy cycle, decision-making, was a particularly long process for health- care reform. The federal legislative process is not only multilayered, but also lengthy. (See the following legislative process section.) This stage involves negotiation and most often compromise from the various stakeholders. For the ACA, this meant Republicans and Democrats debated key components of the bill. One of the most controversial elements of the ACA at this stage was the inclusion of the individual mandate (requiring individuals to maintain health insurance cover- age or pay a penalty), which remained in the final version of the law. Pro-life Republicans felt the Act lacked language to assure them that federal money would not be used to support abortions. To allay these concerns, President Obama issued Executive Order 13535 (Ensuring Enforcement and Implementation of Abortion Restrictions in the Patient Protection and Affordable Care Act) (Shear, 2010), which “ensures that federal funds are not used for abortion services (except in cases of rape or incest, or when the life of the woman would be endangered)” (Executive Order No. 13535, 2010, § 1).

The fourth stage of the policy cycle, policy implementation, is staggered at various stages. For the ACA, benefits from compliance with the individual mandate went into effect January 1, 2014. The employer mandate requiring businesses to offer health insurance to their employees was phased in beginning in 2015, and other parts of the reform are scheduled to be enacted through 2020 if the act remains in its current form.

The fifth stage of the ACA policy cycle, policy evaluation, began when the government launched the state insurance exchanges in October 2013. Given that full implementation would not occur until 2020, the completion of the fifth stage of the cycle would similarly be staggered. In the end,

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the policy cycle of the ACA, or any health policy, is ongoing and fluid. Policy analysts have yet to make their final verdict on the success or failure of this policy.

Legislative Process

The Affordable Care Act also can be used as an example of the legislative process as it relates to healthcare legislation. First, both federal and state governments pass healthcare legislation. However, almost all specific health regulations and laws are state-based. Federal health law con- sists of activities associated with the HHS and other health agencies, such as the Centers for Medicare & Medicaid Services, the Food and Drug Administration, and the Centers for Disease Control and Prevention.

Accordingly, the ACA is a federal law, and like all other federal laws, followed a particular legis- lative process, or a set of procedures that result in the enactment of laws (see Table 8.2). During every session of Congress thousands of bills are introduced and proposed as new laws. In the case of the ACA, it was originally introduced as the Healthy Americans Act sponsored by Senator Ron Wyden in January 2007. The bill initially attracted bipartisan support, but died in committee.

Table 8.2: Steps in the federal legislative process

Step Description

1 Referral to committee

2 Committee action

a. Subcommittee review and hearings

b. Mark-up sessions

c. Committee action to report a bill

d. Publication of a written report

3 Scheduling floor action

4 Debate

5 Voting

6 Referral to other chamber

7 Conference committee action

8 Final floor action

9 Executive action

10 Congressional override

The debate surrounding healthcare reform was reignited during the 2008 presidential election. Following his inauguration, President Obama announced his intention to work with Congress to formulate a comprehensive reform of the U.S. healthcare system. By July 2009, committees within the House of Representatives approved a series of bills (see Table 8.2, Step 2). During the period between June and September of that year, the Senate Finance Committee held more than 30 meetings drafting what later became the foundation of the Senate’s healthcare reform bill.

When Congress resumed in the fall of 2009, negotiations began regarding the details of the policy, and on November 7, 2009, the House of Representatives passed its version of healthcare reform

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known as the Affordable Healthcare for America Act. The Senate passed an alternative reform bill, The Patient Protection and Affordable Care Act (or Affordable Care Act), on December 24, 2009. After much negotiation, the House passed the Senate’s bill on March 21, 2010, and the President signed the Affordable Care Act into law on March 30, 2010. Ultimately, the Supreme Court upheld the constitutionality of the law on June 28, 2012.

Summary and Resources This chapter describes the U.S. public health system at its various geographic levels. Beginning with the federal level, the government has three main functions: assessment, policy development, and assurance. These are carried out by the various federal health agencies, such as the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA).

Although always collaborating with its federal partners, states are ultimately responsible for the health of their populations. For instance, states are the ones to license physicians and hospitals. They are also responsible for understanding the incidence and distribution of disease in their states.

However, the real providers of public health are the local health departments and agencies. These entities not only perform key public health functions (e.g., sewage disposal and sanitation ser- vices,), but they also offer personal health services (e.g., immunizations and well-baby care).

These geographic levels are not truly distinct. Macro-level processes such as urbanization, glo- balization, and industrialization have increased the speed and ease at which diseases are spread. Therefore, a local public health issue can quickly escalate to the national level. This is why it is particularly important for the public health system to work closely with the private health- care system. Despite differences in their goals, each health system is ultimately concerned with improving and maintaining the health of society.

Both the public and private health systems are involved in developing public health policies and implementing them. Recent public health policies have largely been concerned with access to quality affordable healthcare in the United States. However, these policies do not emerge over- night Lengthy processes that follow a policy cycle and legislative process have produced what most analysts call the most significant public health policy of modern times.

Key Terms

allocative policies A category of health policies designed to provide benefits to some distinct group or class of individuals or organizations, at the expense of others.

assessment One of the three main functions of public health agencies at the federal level, which involves the responsibility for systematically understanding the community health needs of a population.

assurance One of the three main functions of public health agencies at the federal level, which involves the management of financial resources that facilitate putting policy into action.

distributive policies A type of public health policy that spreads benefits throughout a given population rather than exclusively on underserved populations.

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endemic A disease or condition regularly found among particular people or in a certain area.

epidemic A rate of disease incidence in a given population that is significantly higher than what is expected based on the past.

epidemiology A field of science concerned with the incidence, distribution, and control of disease.

federal health agencies The part of the federal government responsible for the health of the population through its three main functions—assessment, assurance, and policy development.

germ theory The theory that microscopic organisms, such as bacteria and viruses, can cause disease.

globalization The increasingly connected nature of societies across the globe, facilitated through the development and use of technology, which has been associated with the greater ease and speed of the spread of disease.

health The general condition of one’s body and mind free from illness and disease.

health policy The combination of laws and regulations that underlie the health mission of a government that is implemented at various geographic levels.

industrialization The change of economies from agricultural to industrial, which brought exposure to new toxins and pollution to humans.

infectious diseases Health conditions that can be spread from one person to another.

legislative process A set of procedures that result in the enactment of laws.

market-entry regulations Public health policies that focus on licensing of practitioners and organizations.

market-preserving regulations Public health policies that establish and enforce rules of con- duct for market participants.

noncommunicable diseases Noninfectious behavior-related diseases, such as obesity, diabe- tes, and hypertension.

notifiable diseases A list of diseases that each state is required to report to national surveil- lance programs.

policy cycle A way to understand the process of creating health policies.

policy development One of the three main functions of public health agencies at the federal level, which involves the creation of public health policy through its legislative role. In order to achieve this, the federal government collaborates with other healthcare organizations, such as healthcare professional associations.

public health emergency A declaration made by the federal government with the purpose of releasing essential resources to contain an actual or possible public health crisis.

public health system A system responsible for the health of a population or community.

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quality control regulations Regulations intended to ensure that health service providers adhere to acceptable levels of quality in the service they provide and that producers of health- related products meet safety and efficacy standards.

quarantine A common public health strategy aimed to reduce the spread of infectious disease through the separation of healthy people from those who are infected.

rate or price regulations Public health policies designed to control the growth of prices.

redistributive policies A type of public health policy that aims to level the playing field by providing subsidies to a particular segment of the population that is underserved.

regulatory policies Public health policies designed to influence the actions, behaviors, and decisions of others to ensure that public objectives are met.

reportable diseases A limited list of diseases that spread easily through intimate or close con- tact that are monitored and reported through surveillance programs.

social regulations Public health policies established in order to achieve socially desirable out- comes and to reduce socially undesirable outcomes.

surveillance A system employed by public health officials to collect, analyze, and understand a population’s health-related data in order to plan for the present and the future.

translational research A type of scientific research, which aims to translate basic scientific findings into therapeutic interventions for patients.

urbanization The mass movement of people from rural to urban areas, which has been linked to the spread of disease.

Critical Thinking Questions

1. How are the roles and goals of the public health system different from the private healthcare system in the United States? Please give two examples.

2. Describe how the main functions of public health agencies at the federal level (i.e., assess- ment, policy development, and assurance) can be applied to efforts that promote healthy lifestyles (i.e., diet and physical activity).

3. What do you think is the most pressing public health issue in the United States? How would you address this problem?

4. Do you think the government is playing an appropriate regulatory public health role in the everyday lives of Americans? If yes, explain how Americans benefit from public health regu- lations. If not, what policy changes do you recommend?

5. How would a distributive policy aimed to improve access to affordable healthy food in the United States differ from one that is redistributive?

Suggested Resources

Papers and books

Landon, B. E., Wilson, I. B., Cohn, S. E., Fichtenbaum, C. J., Wong, M. D., & Wenger, N. S. (2003). Physician specialization and antiretroviral therapy for HIV: Adoption and use in

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a national probability sample of persons infected with HIV. Journal of General Internal Medicine, 18, 233–241.

U.S. Department of Health and Human Services (HHS). (2013a). Guidance on allocating and targeting pandemic influenza vaccine. http://www.flu.gov/images/reports/pi_vaccine_alloca- tion_guidance.pdf

U.S. Department of Health and Human Services (HHS). (2013b). Public health and healthcare systems evaluation. http://www.phe.gov/Preparedness/planning/evaluation/Pages/phhse.aspx

Websites

American Public Health Association (APHA): http://www.apha.org/

Bureau of Primary Healthcare (BPHC), Health Resources and Services Administration (HRSA): http://bphc.hrsa.gov/

Office of the Assistant Secretary for Preparedness and Response (OASPR), Public Health Emergency: https://www.phe.gov/about/pages/default.aspx