America’s Public Health System – Part 4
Structural Strategies for Rebuilding Our Public Health System
This is the first of the final two essays in Civic Way’s series on public health. In our last essay, we addressed some of the causal factors for the public health system’s decline. In this essay, we recommend several structural strategies for revamping the public health system. In the next essay, we will present other strategies for improving public health. The author, Bob Melville, is the founder of Civic Way, a nonprofit dedicated to good government, and a management consultant with over 45 years of experience improving government agencies.
Highlights:
If nothing else, the Covid-19 pandemic should alarm us about the ability of our public health system to protect our nation against the plagues to come
We must change the way we think about healthcare (medical care) and replace our siloed treatment-based model with a connected, prevention-based public health model
Under the US Constitution, Article I, Section 8 and CDC leadership, we should rebuild and regionalize the federal public health system to defend us against future health threats
We should merge our 2,900-plus public health agencies into an agile, coordinated network of up to 20 regional agencies and, within each region, up to 35 local public health districts
We need a new public health funding model, with a permanent Public Health Fund, reliable sources (including federal excise taxes) and multi-year, outcome-driven grants for local health districts
Where We Are
The US’ public health system, after decades of success in preserving public health and helping us live longer, is dying a slow death. US life expectancy, after stagnating for the decade before 2020, has fallen since Covid-19 began. Since the pandemic forced many public health agencies to suspend or curtail other public health programs, our future health outcomes are unlikely to improve.
Our national response to the Covid-19 pandemic, with some exceptions, leaves much to be desired. It is easy to blame political leaders like the former President and some of our more craven governors, but many of our failures are systemic. The public health system suffered from a fragmented structure and chronic underfunding for years before the pandemic. The more recent (and shameful) political attacks have certainly exacerbated matters, but the systemic deficiencies long preceded the senseless politics.
As hard as it is to look past the Covid‑19 pandemic, we must. If this pandemic is a harbinger of graver plagues to come, we should be very worried. The public health system’s structural and fiscal weaknesses, coupled with the recent political attacks, have diluted our good faith efforts to combat the pandemic. If we fail to make fundamental changes to our public health system today, we may not survive the next one.
Aligning Public Health with Medical Care
There are many promising ideas for improving our public health system, but the single most important call to action is to tear down the wall between public health and health (medical) care. We must change the way we think about healthcare in America. We must shift our healthcare orientation from treatment to prevention and replace our siloed healthcare model with a connected public health model.
This effort should begin at the federal level with the full integration of federal Public Health Service (PHS) and Centers for Medicare and Medicaid Services (CMS). The Department of Health and Human Services (DHHS) must improve the coordination of public health and healthcare resources and fully align patient-based clinical treatment services with community-based prevention programs.
DHHS also should adopt a dramatically new fiscal model, one that shifts more funds from treatment programs to prevention (public health) programs. Over time, this new model should significantly increase the federal government’s share of health spending on public health (hopefully, bringing the US into line with the spending ratios of other industrialized nations). This shift should occur gradually, but its ultimate impact should be to dramatically decrease government spending on preventable medical treatments.
There are many paths to this goal. One option is for Congress to establish a dedicated federal fund for public health programs and allocate a higher ratio of Medicaid and Medicare costs to that fund (or to other healthcare services like primary care). Another option is to restructure public health grants and make them flexible enough to promote the cross-jurisdiction coordination of local public health programs.
Still another strategy is to revamp the federal health insurance programs to incentivize prevention initiatives. Reform reimbursement mechanisms to improve primary care access and help prevent the chronic conditions underlying many illnesses. Improve federal coverage of (and access) to nonmedical services that improve health outcomes (e.g., community-based healthy eating and activity campaigns).
At the local level, we should forge stronger bonds between healthcare providers (e.g., hospitals) and public health agencies. We should do so by restructuring healthcare financial incentives from filling beds and performing procedures to improving health outcomes. We also should improve data sharing among healthcare providers and public health agencies and give public health data the same priority as healthcare data.
Rearming the Federal Public Health System
Public health is no less a national defense asset than the armed forces. Federal law should treat federal public health functions, particularly the war against transmittable diseases, as the national defense activities that they are. Federal law should clarify federal authority for public health under the US Constitution (Article I, Section 8) to provide for the “common defense and general welfare."
The Congress should enact, and the President should sign, legislation merging all federal public health programs under DHHS. This legislation should require the transfer of any public health programs residing with other federal departments (e.g., Agriculture, Education and EPA) to DHHS. It should require DHHS to improve the integration of all Public Health Service (PHS) units, including the CDC, FDA, NIH and National Center for Health Statistics, with the relevant CMS units. And it should clarify the CDC’s authority as the lead federal agency for fighting transmittable diseases and working with global entities (e.g., World Health Organization).
The President should rebuild the federal public health system with the CDC as the foundation. Restore the CDC Director’s independence. Establish a National Council on Domestic Health to oversee the CDC’s pandemic-fighting work. Strengthen the CDC’s authority to marshal private sector resources (e.g., the Defense Production Act). Expand the CDC’s pandemic-fighting resources (e.g., scientists, researchers and Commissioned Corps).
Finally, DHHS should establish a network of regional public health hubs around the 15 to 20 largest population centers. This will likely require the DHHS to reorganize the service areas of current regional offices[1] and add regional offices for areas without regional offices (e.g., Los Angeles, Phoenix, Minneapolis, Cincinnati, Miami and Honolulu). The regional public health districts must have sufficient power to protect our public health and mandate public health measures.
Regionalizing our Public Health System
Using its constitutional powers to defend the American public, the federal government should work with the states to reorganize the nation’s 2,900-plus public health agencies around its 15 to 20 largest regions. This will involve the transfer of primary public health powers and duties from the states to the new regions.
Each region should have 25 to 35 local public health districts organized around urban and rural constituencies (with comparable service populations). This will require the merger of most of our state and local health agencies (and the abandonment of our fragmented parochial model), but it will dramatically reduce bureaucratic barriers and improve the sharing and coordination of resources across local jurisdictions. These local public health districts will serve as the nation’s first line of public health defense.
Governance should be representative. Each region should have a governing body (board of health) comprising elected state representatives (e.g., governors or legislators). Similarly, each district should have a governing body comprising elected local representatives (e.g., mayors or county commissioners). The major political affiliations (Republican, Democrat and Independent) should be equally represented. Every region and district should have a chief operating officer (chief medical officer) reporting to the governing body.
Emergency communications should be recognized as an essential public health/public defense function. To that end, we should merge and regionalize the estimated 5,000 911 call centers as part of a national public health and safety communications system. We also should upgrade and standardize the operating capacities of these regional centers. Access to comparable resources like mobile crisis response teams. Uniform standards for dispatch protocols, training programs, data systems, performance metrics and management reports.
Redesigning the Public Health Funding Model
The images of overwhelmed ICU units and hospital workers during Covid-19 have been disturbing. Still, it is no secret that our failure to prevent illness enriches many hospital coffers. During our darkest times, many hospitals are highly profitable. During 2020, for example, Florida hospitals generated about $6.3 billion in net income. In turn, as providers like hospitals and long-term care facilities amass larger financial portfolios, the hospital-industrial complex garners more power and money.
There is little debate that our nation needs more money to meet its public health challenges. At the state and local level, for example, the Public Health Leadership Forum and Robert Wood Johnson Foundation have estimated that at least $4.5 billion more is needed every year. From what sources will this extra funding come?
One source is the healthcare industry. Since the US spends more on healthcare (and less on public health) than other industrialized nations, shouldn’t we shift our priorities? Instead of spending only three percent of our total $3.6 trillion health care bill on public health, perhaps we should spend at least 10 percent. There is nothing inherently wrong with large hospital chains being profitable, but redirecting a modest share of these profits to public health programs that prevent illness would be profitable for all.
A related source is the federal government which spends so much on healthcare (e.g., Medicare and Medicaid). Directing even a small share of those budgets to matching local public health initiatives (e.g., reduce health inequities) could have a disproportionate impact on overall healthcare spending and make us all healthier. Another source could be private foundations which should be encouraged to revamp their financing mechanisms to allocate more resources to public health initiatives.
However, an infusion of more money is not, in and of itself, the answer. While more money is needed for local health programs (e.g., communicable disease tracking, health inspections, child vaccinations and maternal aid), the manner in which it is allocated and distributed also matters.
The nation’s public health funding model must be stable, multi-year, outcome-driven and efficient. For example, a permanent Public Health Fund. A dedicated, predictable federal funding stream covering at least 90 percent of annual public health needs for five-year cycles. Tied to quantifiable goals (e.g., national accreditation and community metrics). And, once allocated, it must be distributed efficiently.
Federal funding must be increased for critical national pandemic preparedness functions, including viral research, infectious disease prevention and vaccine development. Such agencies as the CDC and NIH must be adequately funded to defend the nation from emerging health threats (e.g., bioterrorism).
Federal funding streams must be integrated to improve health outcomes across regions. Promoting preventive services (e.g., dietary, exercise and lifestyle programs). Cutting environmental perils (e.g., lead poisoning). Aligning food and housing initiatives (e.g., SNAP, WIC and Section 8). Leveraging Medicare and Medicaid to help beneficiaries reduce threats (e.g., obesity, smoking and opioids). Improving Medicaid reimbursement for primary, prenatal and postpartum care. Promoting interstate compacts (e.g., resource sharing and licensure) and tying local public health agency to national standards (e.g., public health accreditation).
The funding source also matters. If, for example, individuals insist on maintaining unhealthy practices—choices that bring higher healthcare costs for all of us—they should bear higher costs. Better cost accounting demands federal excise taxes or surcharges on items that drive chronic illnesses, including tobacco products, alcohol, soda and processed food. And such fees can be used to not only reduce healthcare costs (e.g., drug prices), but help ease the transition to a healthcare funding model that promotes personal responsibility.
Conclusion
We cannot build the public health system we need without the sweeping structural and financial changes recommended above. However, even these strategies won’t be enough.
In our next essay, we propose some other vital actions for protecting our nation from the public health threats on the horizon. Modernizing our public health laws and regulations. Revitalizing local public health agencies. Rebuilding and diversifying the public health forces, including workers and community partners. Finally, upgrading public health information systems and communications capabilities.
[1] The DHHS has ten regional offices: Atlanta, Boston, Chicago, Dallas, Denver, Kansas City, New York, Philadelphia, San Francisco and Seattle.