Chapter 11

Public Health and the Role

of Government in Health
Care

CHAPTER OBJECTIVES
Define and characterize public healths core
functions, responsibilities of the public health
sector and public health code of ethics
Understand the history and evolution of
governments 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 groupsthe 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

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 & diseasespecific 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

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 1930s.

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 Childrens
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 worlds 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

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 governments 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
1. Assessment: collect, analyze data to define
population health status, quantifying
existing or emerging health problems
2. Policy development: generate
recommendations from data to intervene,
mobilize public & community organizations
3. Assurance: government public health
agencies ensure basis health delivery
components are in place

10 Essential Health Department

Responsibilities
1. Monitor health status, solve community
problems
2. Diagnose & investigate health problems &
hazards
3. Inform, educate, empower people about
health issues
4. Mobilize community partnerships &
actions to solve health problems
5. Develop policies & plans to support
individual & community health efforts

10 Essential Health Department

Responsibilities
6. Enforce laws and regulations to protect health
and ensure safety
7. Link people with personal health resources &
ensure health care availability
8. Provide competent public & personal health
workforce
9. Evaluate effectiveness, accessibility, quality of
person- and population-based health services
10.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

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 CDCs 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:
1. Address causes of disease, aiming to
prevent adverse health outcomes
2. Respect rights of individuals in the
community
3. Ensure input from community members
4. Advocate for and empower
disenfranchised
5. Seek information for effective policies &
programs

Public Health Ethics (4)

Twelve ethical principles (synopsis), contd
7. Act in a timely manner
8. Respect diverse values, beliefs, cultures
9. Enhance the physical and social
environment
10.Protect confidentiality; justify exceptions
11.Ensure professional employee competence
12.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 20102015; $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, contd
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

ACA and Public Health-Major Provisions

(4)
Increase access to clinical preventive services, contd
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,
contd
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

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 HealthSummary

ACA recognizes and supports centrality
of public health concepts, principles and
practices in improving Americans 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