Transcript hca_340_chapter_11

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 ablebodied 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 nonpublic 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
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 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 IOMcited 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
6. Obtain community consent for policies
Public Health Ethics (4)
• Twelve ethical principles (synopsis), cont’d
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 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 lowincome, 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