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Chapter 11

Public Health and the Role of Government in Health Care

CHAPTER OBJECTIVES

  • Define and characterize public health’s core functions, responsibilities of the public health sector and public health code of ethics
  • Understand the history and evolution of government’s roles in health care and relationships with private medicine
  • Review challenges in implementing a population focus in U.S. health care delivery system
  • Review major provisions of the ACA affecting public health

Public Health Defined (1)

“Efforts made by communities to cope with health problems arising from people living in groups…the need to control transmission of disease, maintain a sanitary environment, provide safe water and food, and sustain people with disabilities and low income populations.”

Public Health Defined (2)

  • Public health concepts reflect:
  • Current knowledge of the nature and causes of diseases
  • Practices of disease control and treatment
  • Dominant social ideologies of communities
  • Grounded in social justice, applies medicine, epidemiology, statistics, social, behavioral, environmental, other disciplines

Public Health Defined: Ecological Models

  • Incorporate numerous “determinants” that impact health status of groups, e.g. physical environments, political conditions, human biology, socio-economic factors, behavioral choices, cultural norms
  • Explain “healthy state” or its absence; facilitate development of effective interventions

Early Origins of Public Health (1)

  • Hebrews: spiritual cleanliness and community responsibilities
  • Greeks: personal hygiene to achieve mind/body balance
  • Romans: water systems, sewage disposal & swamp drainage; infirmaries for sick, poor were first “public hospitals”

Early Origins of Public Health (2)

  • Medieval Period- Overpopulated, filthy walled towns spawned epidemics, superstitious, demonic and theological theories of disease displaced earlier attention to personal hygiene and sanitary environment.
  • Renaissance Period- rebirth of art, literature and science; production and world trade demanded healthy laborers and soldiers; centralized government public health measures.

Public Health in England

  • Poverty, illness, disability common; support for medical care in private homes, public infirmaries
  • Elizabethan Poor Laws of 1601: government provisions for the “lame, impotent, old, blind, and such other among them being poor and unable to work.”

Public Health in England

  • 17th century: first collection, analysis of national data on industrial production, demographics; population & disease-specific mortality rates linked social factors with health and disease (William Petty, John Graunt)
  • 18th century: John Bellers exhorted national responsibility for hospitals, labs and medical care; population health should be a national concern.

Public Health in England

  • Poor Law Amendment Act of 1834: reduce public dependency, spur productivity; aid only to able-bodied in exchange for labor in workhouses
  • Poor Law Commission: linked health conditions to the economy; data linked population characteristics, environmental conditions with disease incidence
  • After years of debate, 1848 Public Health Act passed creating General Board of Health, a model national public health service

Development of U.S. Public Health & Government-Supported Services (1)

  • Colonial period->1800s: Strong influences of the British model: NY Poor Law (1788) established almshouses
  • Epidemics stimulated sanitary reforms
  • Almshouses and town-employed physicians dominated till the 1930’s.

Development of U.S. Public Health & Government-Supported Services (2)

  • 1850: Lemuel Shattuck, statistician: conducted U.S. sanitary surveys of morbidity, mortality rates related to environmental conditions; advocated city, state responsibility
  • Sanitary Commission Report: First ignored, now most influential document in evolution of U.S. public health; emulated Chadwick
  • 1865: NYC Council of Hygiene and Public Health expose created Board of Health, U.S. turning point

Development of U.S. Public Health & Government-Supported Services (3)

  • Early U.S. public health initiatives motivated more by economic than humanitarian concern
  • USPHS est. 1798 as Marine Hospital Service to care for ill sailors in seaport cities; 1870-Marine Hospital system reorganized as national system with “Surgeon General” in charge (Dept. of the Treasury)
  • 1889: Congress est. Public Health Service Commissioned Corps, a mobile physician corps to assist with disease control & health protection

Development of U.S. Public Health & Government-Supported Services (4)

  • 1891: Staten Is. Marine Hospital lab moved to D.C.; forerunner of the NIH
  • 1912: Marine Hospital Service renamed U.S. Public Health Service; became major agency of DHHS
  • 1933: Federal Emergency Relief Act; optional federal aid to states for acute & chronic medical & nursing care, obstetrics, drugs & supplies

Development of U.S. Public Health & Government-Supported Services (5)

  • 1970s: National Institutes of Health created for disease, occupational health & safety research
  • 1979: Dept. of HEW renamed Dept. of Health & Human Services; education moved to its own department
  • 2013: DHHS budget $ 941 B; health protection, promotion, provision of health, other human services to vulnerable populations; 300 programs through 10 operating divisions (~65,000 employees)

DHHS Operating Divisions (1)

  • National Institutes of Health (NIH): 18 health institutes, National Library of Medicine, National Center for Complementary & Alternative Medicine; 30,000 research projects
  • Food and Drug Administration (FDA): food, cosmetic, drug, biological product safety
  • Centers for Disease Control and Prevention (CDC): monitors disease trends, disease, injury investigations and control measures

DHHS Operating Divisions (2)

  • Indian Health Service (IHS): operates hospitals, health centers, health stations serving 1.5 M of 500+ tribes
  • Health Resources and Services Administration (HRSA): multiple programs serving needy; FQHCs; health professional training for underserved areas
  • Substance Abuse and Mental Health Services Administration (SAMHSA): quality & access to substance abuse prevention, addition treatment, mental health services, HIV/AIDS services

DHHS Operating Divisions (3)

  • Agency for Healthcare Research and Quality (AHRQ): research to improve quality, reduce costs, improve patient safety; evidence-based research
  • Centers for Medicare & Medicaid Services (CMS): administers these and Children’s Health Insurance Program
  • Administration for Children and Families (ACF): 60+ programs, e.g. Head Start, child support enforcement, TANF, domestic violence, adoption, foster care

DHHS Operating Divisions (4)

  • Administration on Aging (AoA): administers federal programs under the Older Americans Act, e.g. meals on wheels, community level programs to support older persons and their caregivers.

Veterans Administration (1)

  • First established for disabled, indigent Civil War veterans under Department of Defense:
  • One of world’s largest delivery systems:
  • 155 medical centers
  • 900+ ambulatory care & outpatient clinics
  • 135 nursing homes
  • 47 residential rehabilitation treatment programs
  • 232 veterans’ centers

Department of Defense Military Health Service Program

  • Federal support for direct care & support services for ~8.1 M military personnel & dependents, military retirees, families & others entitled
  • World wide: 98 hospitals, 480 clinics
  • TRICARE: civilian workers covered under managed care

States’ Roles in Public Health

  • Contribute ~14% of total national health care expenditures
  • Operate or support hospitals, support medical schools, operate mental institutions; health departments that conduct infectious disease monitoring & control, support primary & preventive health services at state and local levels

City and County Roles in Public Health

  • Health departments: direct services, primary prevention, epidemic surveillance and control
  • 1000+ public hospitals and health systems provide “safety nets” & services unattractive to other hospitals
  • Crisis response for public health emergencies
  • Special services for medically needy & low income populations

Decline in Influence of Public Health Service (1)

  • Despite impressive contributions, funding always competed for more highly valued demands of health sector
  • 1960s: professionals, political leaders, media criticized grants to state, local agencies as ineffective
  • New, important programs assigned to non-public health agencies: Medicare, Medicaid, Head Start, others assigned outside of public health service

Decline in Influence of Public Health Service (2)

  • 1970s: ended “Creative Federalism”: Nixon opposed federal, state, local public health system; federal responsibilities moved to states
  • 1980s: Reagan continued more extreme measures; block granted Federal funds; decline of government’s organized system of public health accelerated
  • 1985: IOM Report on status of public health: failures of policy development; politicization of public health agencies; ambiguous responsibilities among levels of government

Responsibilities of the Public Health Sector (1)

  • Healthy People 2000, National Health Promotion and Disease Prevention Objectives: (response to 1988 IOM concerns)
  • 90% of population should be served by local health departments that carry out core public health functions: Assessment, Policy Development, Assurance

Responsibilities of the Public Health Sector: Core Functions

Assessment: collect, analyze data to define population health status, quantifying existing or emerging health problems

Policy development: generate recommendations from data to intervene, mobilize public & community organizations

Assurance: government public health agencies ensure basis health delivery components are in place

10 Essential Health Department Responsibilities

Monitor health status, solve community problems

Diagnose & investigate health problems & hazards

Inform, educate, empower people about health issues

Mobilize community partnerships & actions to solve health problems

Develop policies & plans to support individual & community health efforts

10 Essential Health Department Responsibilities

Enforce laws and regulations to protect health and ensure safety

Link people with personal health resources & ensure health care availability

Provide competent public & personal health workforce

Evaluate effectiveness, accessibility, quality of person- and population-based health services

Research for new insights & solutions to environmental health problems

Responsibilities of the Public Health Sector (5)

  • Healthy People 2010: recognized that HP 2000 failed to meet 85% of 319 targets; HP 2010 noted progress in 71% of targets, but “disparities not changed for 80% of objectives and increased for 13%.”
  • HP 2020 continues 2010 objectives with many additional topics, e.g. adolescent health; gay, lesbian, bisexual, transgender health; global health, genomics, older adults

Relationship of Public Health and Private Medicine (1)

  • Complementary roles with differing points of attention: preventive for population groups versus curative for individuals
  • Public health and clinical medicine “separated” in the 1940s as medicine pursued scientific, hospital-based services, less attention to community health
  • Separation continued with packed medical school curricula and faculty lacking public health experts

Relationship of Public Health and Private Medicine (2)

Persistent discord between public health and clinical medicine:

  • Public health equated with government bureaucracy
  • Public health linked with low income populations
  • Private MDs equate patient service to “community service,” paid only for “active practice”
  • Public health accomplishments in infectious disease & sanitation “invisible,” so not “politically attractive”
  • ACA may help close gap with population-based approaches aligned with reimbursement incentives

Opposition to and Cooperation with Public Health Services

  • Struggles with limits of public health mandate
  • Fears of “socialized medicine;” intrusions of government services into private practice; mandated infectious disease reporting usurped patients’ confidential physician relationships
  • Synergistic private/public medicine
  • Adult and child immunizations
  • Disease screening programs partner public health initiatives with private practices

Resource Priorities Favor Curative Medicine over Preventive Care

  • 1981-1993: Emergence of HIV/AIDS; reemergence of tuberculosis, measles; escalating substance abuse, violence, teen pregnancy
  • Total U.S. health expenditures increased 210%; public health funding declined 25%
  • Investments in high-tech curative efforts (e.g. funding for neonatal intensive care) far outstrip more effective, far less costly preventive strategies

Challenges of Disenfranchised Populations

  • Major causes of disease, disabilities among disenfranchised individuals result from multiple causes not amenable to technological remedies
  • Evidence that behavior & environment are responsible for 70%+ of avoidable mortality; effective interventions not integrated into medical care
  • Lack of reimbursement for lifestyle, behavioral interventions in clinical medicine

Public Health Services of Voluntary Agencies (1)

  • Private not-for-profit agencies share responsibilities with government for filling service gaps for needy and special populations
  • Providers: hospitals, nursing homes, home care, medical & vocational rehabilitation, hospice, disease/condition-oriented organizations, e.g. asthma, reproductive health, etc.

Public Health Services of Voluntary Agencies (2)

  • Not-for-profit foundations support community and population health initiatives to stimulate research, demonstration projects and public/private/academic partnerships

Changing Roles of Government in Public Health

  • Federal, state, local government involvement in public health remains substantial at all levels
  • Roles are evolving with system reforms; many states now combine health and social services agencies for particular population groups
  • National and state support of public health activities has moved toward increased privatization in line with market consolidations and expansion of for-profit enterprises

Public Health in an Era of Privatization

  • Declines in public health funding and constrained state and local budgets led to downsizing of state and local health departments and service outsourcing
  • Health departments maintain essential services but often at considerably reduced levels

Government Challenges in Protecting Public Health (1)

  • State and local deficits result in downsizing public health services while business leaders recognize importance of healthy worker populations
  • Terrorist attacks of 2001 sparked federal attention to public health “defense” with new Dept. of Homeland Security (DHS)…22 new and existing agencies

Government Challenges in Protecting Public Health (2)

  • DHS activities were disjointed across 50 state and 3,000 local agencies
  • No nationally consistent plans and systems development (evident in disasters such as Katrina)
  • States and localities constructed individual goals and priorities
  • Six years of post-911 preparedness funding failed to yield comprehensive, national capabilities

Public Health Ethics (1)

  • 1988 IOM report, The Future of Public Health, spawned CDC’s 1990 creation of the National Public Health Leadership Institute (PHLI)
  • convene public health leaders to address IOM-cited deficiencies & collaborate to meet challenges
  • PHLI graduates created the “Public Health Leadership Society;” identified need for a public health code of ethics

Public Health Ethics (2)

  • Code of ethics recognized that ensuring and protecting public health is inherently moral; code draws from ethical principles of human rights, distributive justice, duty to take action as an ethical motivation.
  • Differs from medical ethics concerned with individuals, public health code concerned with institutions’ interactions with communities.
  • APHA adopted code in 2002; followed by many others

Public Health Ethics (3)

Twelve ethical principles (synopsis) reflect institutions’ relationships with communities:

Address causes of disease, aiming to prevent adverse health outcomes

Respect rights of individuals in the community

Ensure input from community members

Advocate for and empower disenfranchised

Seek information for effective policies & programs

Obtain community consent for policies

Public Health Ethics (4)

  • Twelve ethical principles (synopsis), cont’d

Act in a timely manner

Respect diverse values, beliefs, cultures

Enhance the physical and social environment

Protect confidentiality; justify exceptions

Ensure professional employee competence

Build public trust and institution effectiveness

ACA and Public Health-Major Provisions (1)

  • National Prevention, Health Promotion and Public Health Council (the Council); headed by Surgeon General; 17 federal agencies, 22 member presidentially appointed Advisory Group
  • Four directions: 1) building healthy, safe communities, 2) expanding clinical and community preventive services, 3) empowering healthy choices, 4) eliminating health disparities

ACA and Public Health-Major Provisions (2)

  • Council 2012 report outlined 50 key indicators aligned with evidence-based data sources on the 4 key directions
  • Prevention and Public Health Fund: the first mandatory funding stream to improve public health; $ 7B fiscal 2010-2015; $2 B each succeeding year; restrain costs, improve health
  • Local, state, federal programs: curb tobacco use, increase primary/preventive care access

ACA and Public Health-Major Provisions (3)

  • Public Health Fund, cont’d
  • Local, state, federal programs: curb tobacco use, increase primary/preventive care access
  • Help states and local communities respond to public health threats and outbreaks
  • Increase access to clinical preventive services:
  • Medicare coverage for annual wellness/preventive services visits without copays or deductibles

ACA and Public Health-Major Provisions (4)

Increase access to clinical preventive services, cont’d

  • Increase state Medicaid funding for preventive services and incentives for beneficiaries’ participation in healthy lifestyles programs
  • Increase funding for FQHCs

  • Prevention and Public Health Innovation
  • Federal health program funding to collect and report data on indicators of disparity
  • Funding for education, technical support for workplace wellness

ACA and Public Health-Major Provisions (5)

  • Prevention and Public Health Innovation, cont’d
  • CDC support for state, local, tribal agencies’ improvement in surveillance of and responses to infectious diseases, other conditions affecting community health
  • Health Care Workforce: Improve access to health care services, especially for low-income, uninsured, minority, health disparity and rural populations

ACA and Public Health-Major Provisions: Health Care Workforce

  • Recognizes shortages of primary care and public health professionals in underserved areas
  • Establishes National Health Workforce Commission: review current/projected needs, recommend federal policies to align with needs; competitive grants for state-level workforce planning and development strategies

ACA and Public Health-Major Provisions: Health Care Workforce

  • Student loan repayments for public health students & allied health professionals working with underserved populations in public health agencies
  • National Health Service Corps scholarships and loan repayments within USPHS for “Ready Reserve Corp” to respond to national emergencies
  • $ 50 M for nurse-managed health clinics

ACA and Public Health-Major Provisions: Health Care Workforce

  • Training programs in cultural competency, public health, disabled populations
  • Grants for community health workers
  • Fellowship training support for professionals in state and local health departments in applied epidemiology, public health laboratory science, informatics
  • Creates USPHS Public Health Sciences Program to train health professionals in public health disciplines

ACA and Public Health-Major Provisions: Health Care Workforce

  • Creates USPHS Public Health Sciences Program to train health professionals in public health disciplines
  • Reauthorizes programs to attract minority applicants to health professions with commitment to work in underserved areas

ACA and Public Health-Summary

  • ACA recognizes and supports centrality of public health concepts, principles and practices in improving American’s health status
  • ACA provisions respond to needs for emphasis on integrated systems of public and private health care
  • Opportunities for public health and organized medicine to collaborate in innovative ways

The Future

  • Major challenges in changing existing perceptions and practice patterns; a new vision for public health role needed to change entrenched behaviors and organizational commitments
  • Prevention emphasis tied to reimbursement may be key to advancing needed change
  • Opportunities for new, functional relationships between public health and medicine