America’s Public Health System – Part 2
The Structural Breakdown of Our Public Health System
This is the second essay in Civic Way’s public health series. In our last essay, we described the evolution of America’s public health system. In this essay, we discuss the most serious structural and organizational flaws of the public health system. 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:
The US public health system, more archeological dig than modern service model, is plagued by structural issues, including organizational fragmentation and needless bureaucracy
As the federal government’s lead public health agency, the US Public Health Service (PHS), a division of the Department of Health and Human Services (DHHS), includes the CDC, NIH and FDA
The CDC lost some credibility during this pandemic, but offers proven expertise, resources and relationships on which to rebuild America’s public health system
State and local governments are the most visible and numerous governmental entities for protecting public health, but their structures, resources and capabilities vary widely
The fragmentation of nearly 3,000 public health entities is the most serious threat to our public health system, inflating costs, diluting vital services and sapping our pandemic-fighting capabilities
Introduction
The pandemic has taught us that we are only as safe as our weakest public health link. And our public health system has many weak links—not only among federal, state and local public health entities, but between the public health and medical care systems. These badly frayed links jeopardize our public health.
Our public health system is struggling for many reasons. In this essay, we focus on just one of those factors—its organizational model. The way in which public health resources are organized, deployed and coordinated. Its heavy reliance on state and local public health agencies. Its jurisdictional barriers to the coordination we need.
Over time, the system has become a fragmented, poorly coordinated network of nearly 3,000 public health agencies. Several large federal agencies with proven expertise and highly bureaucratic decision-making processes. Over 50 state health agencies with vastly different structures and capabilities. About 2,900 local health agencies with dwindling powers and profoundly dissimilar resources and services.
Organized to Fail
The US public health system is plagued by organizational fragmentation (balkanization). Because it evolved over time, it is more archeological dig than architectural design. In fact, one could be forgiven for concluding that, if it was designed at all, it was designed to fail.
In the aggregate, the US has nearly 3,000 public health agencies. They include at least ten federal agencies with some public health duties, 55 state public health agencies and about 2,900 local public health agencies. Together, these are the entities upon which we depend to protect us from viral outbreaks, contaminants and other community health threats. These are the agencies that preserve and promote public health.
Since our public health system developed under the precepts of American federalism, its functions are distributed across a multitude of federal, state and local governments. In short, it is highly decentralized.
Since many public health issues are national (if not global), the federal government plays a critical public health role, especially during national public health crises. However, state and local governments lead the implementation of most public health policies and programs. For years, this model worked relatively well, especially in confronting localized public health threats.
However, as public health issues and threats became more national and global in scope, our public health system seems less agile.
Public health workers must navigate jurisdictional boundaries that no virus recognizes. To mount a rapid response to a pandemic, they must coordinate resources across many bureaucratic obstacles and jurisdictional boundaries. To counter the speed of viral transmissions, they must rely on inadequate data collection systems and communications capabilities.
The Federal Government and Public Health
During the Covid-19 pandemic (especially during the initial months), it was hard to tell which federal agency was in charge. Rambling White House pressers with mixed messages. A cavalcade of spokespeople. The President. The Vice President. The immunologist and AIDS/HIV hero with the New York accent. The accomplished physician and diplomat with the festive scarves. The virologist and bureaucrat with the Amish beard. The cabinet officer and former drug company CEO.
So, what do we know about the federal government’s public health role and structure? While there was some confusion about federal duties during 2020, they are relatively clear. The federal government’s primary role is to track national public health needs, lead public health research, aid state and local health agencies, lead national responses to public health crises and support global health initiatives.
The federal organizational structure for federal public health duties also seems clear enough. Several federal agencies have public health roles, such as the Environmental Protection Agency, Department of Agriculture (Food and Nutrition Service) and Department of Education (Office of Special Education and Rehabilitative Services). However, there is little doubt which federal agency has primacy in public health—the Department of Health and Human Services (DHHS).
DHHS has the largest public health portfolio and supervises the US Public Health Service (PHS). As the federal government’s lead public health agency, PHS oversees several critical entities:
National Institutes of Health (NIH) – conduct or lead health research projects
Food and Drug Administration (FDA) – set and enforce safety standards for food, drugs and consumer goods
National Center for Health Statistics – collect, analyze and disseminate health data
Centers for Disease Control (CDC) – lead assessment and epidemiologic activities
Other PHS units include the Agency for Toxic Substances and Disease Registry, Substance Abuse and Mental Health Services Administration, Indian Health Service, Office for Preparedness and Response and Agency for Healthcare Research and Quality.
In addition to PHS, DHHS manages the Centers for Medicare and Medicaid Services which controls a significant portion of the nation’s health-related spending. DHHS also operates regional offices in several cities, including Atlanta, Boston, Chicago, Dallas, Denver, Kansas City, New York, Philadelphia, San Francisco and Seattle
The Disappearing CDC
Before Covid-19, the CDC assumed a visible national leadership role in fighting pandemics. It was generally regarded as an independent, objective source of public health counsel. State and local officials relied on CDC support for unpopular public health measures. For prior pandemics (e.g., H1N1, Ebola and Zika), the CDC won plaudits for leading and coordinating the nation’s response.
Since 2020, the federal government’s public health leadership has been questioned and the CDC has been the target of considerable criticism. During the Covid-19 pandemic, the CDC seemed ineffectual. A test kit debacle damaged its reputation. Its mixed messaging undermined public trust. Its archaic data systems undermined its findings. Its director, serving at the President’s pleasure, seemed tentative, more concerned about retaining his job than protecting public health. The White House ultimately muzzled CDC’s leaders and silenced it as an independent voice.
Despite its Covid-19 missteps, the Atlanta-based CDC remains a vital public health resource. With a $12 billion annual budget and 15,000 employees and contractors, it has unparalleled capabilities for fighting infectious disease, food borne pathogens, environmental hazards and occupational threats. It has a virtual army of epidemiologists, physicians and scientists. It even has a uniformed nonmilitary service—the Commissioned Corps—with physicians, nurses, therapists, dentists, pharmacists, dieticians, engineers and sanitarians.
Long revered as the world’s premier public health agency, the CDC offers the foundation on which to rebuild America’s public health system. As we prepare for future public health crises, we cannot afford to overlook its vast expertise and resources, nor its global reputation.
State Government and Public Health
States are the primary governmental entity for protecting public health. Since Massachusetts established the first State Board of Health, 55 state health agencies have formed, one for each of the 50 states plus five more for the District of Columbia and four island territories. These health agencies analyze health data, develop plans, set standards, carry out mandates, manage public health programs (e.g., epidemiology and environmental safety), conduct inspections and lead crisis responses.
The states employ different structures. Eight states employ centralized models in which they directly supervise or operate local public health agencies or operate a single state public health agency (no local agencies). 29 states use a decentralized model with independent local agencies. Another 13 states have hybrid models with both state-run agencies (usually for rural areas) and independent local agencies (usually for large urban areas). Some hybrid models have regional health districts and county public health agencies (e.g., Georgia).
Most state public health agencies are led by a health commissioner or secretary of health. Most states also have a chief medical officer. In some states, the chief medical officer may also serve as the state health agency director. In many states, the governor oversees the state public health agency, subject to the oversight of the state legislature and, in some cases, a state board of health. Some state health agencies are embedded in larger departments. Some states have regional offices to improve local coordination.
Public health systems vary considerably by state. Different laws, policies and structures, including the degree of authority given public health officials. Different program alignments (e.g., public health and environmental). Resource disparities. Different strategies for coordinating local services. Strikingly different health outcomes.
Local Government and Public Health
The most visible public health agencies are local. Subject to state authority, they are the front line of public health. They deliver a range of public health services to their constituents, including screening, immunizations, chronic disease control, sanitation, inspections, school health, maternal and child health, and health education. Some agencies are empowered to enforce public health laws and issue fines.
The most numerous public health agencies are local. There are about 2,900 local health agencies, but the number varies significantly by state. Some states, like Delaware, Hawaii, Rhode Island and Vermont have no local public health agencies (a single state agency). Massachusetts has 350 local public health agencies.
In most states, local public health services are delivered through counties. About 70 percent of local public health agencies are county-based (e.g., Georgia has one public health agency for each county). Some agencies serve multiple counties. And some states have more health agencies than counties (e.g., Ohio has 88 counties, but 125 local health departments). Some states have municipal public health agencies.
The balkanization of public health systems undermines public health in many ways. It yields wide capacity variances (e.g., Boston’s large, sophisticated health department versus nearby one-employee shops). It impedes coordination among local health agencies. It exacerbates resource constraints which, in turn, force some public health officials to reduce disease prevention efforts. It contributes to wide gaps in local disease rates.
Public health leaders are trying to standardize capacities. For instance, the CDC and Robert Wood Johnson Foundation support a national voluntary accreditation program for state, tribal, local and territorial health departments. The Public Health Accreditation Board (PHAB), a nonprofit independent accrediting body, leads development and testing activities and began accrediting health agencies in 2013.
Emergency Communications
Another example of our fragmented approach to local government is emergency communications. While this function is typically carried out by a public safety agency (rather than a public health agency), its fragmentation adversely affects public health programs. Since 911 call centers handle millions of behavioral health emergency calls every year, they have become an essential component of our public health system.
With over 5,000 separate 911 call centers, the national 911 call center system is even more disjointed than the public health system. Not surprisingly, these centers employ widely different operating standards, dispatch protocols, training programs, data systems and management reports. Performance metrics, if they are used at all, vary far more than they should.
A recent survey conducted by Pew Charitable Trusts and the National Emergency Number Association found several problems plaguing 911 call center systems, such as:
Excessive turnover rates among telecommunicators and dispatchers
Too few call center staff with ample behavioral health crisis training
Limited options for dispatching specialized responses to crisis calls
Limited access to specialized mental health resources especially in rural areas
Inconsistent reporting of mental health and substance use-related calls
Not all of these problems are caused by American federalism and our nation’s fragmented local government model, but the sheer number of 911 call centers poses a significant barrier to their resolution.
Our Collective Undoing
Fragmentation is not the only problem undermining our public health system, but it is the most consequential. Even if the other problems challenging public health systems—political interference, funding and staff losses—could be solved, public health programs would still be hampered by an outmoded structure.
Why does this matter?
It poses unnecessary costs on the system. It forces the system to make budget cuts and curtail programs. It impairs our ability to carry out fundamental public health functions like chronic disease prevention programs. It contributes to bureaucratic inefficiencies, coordination failures, wide capacity variations and disparate outcomes. Where one lives can determine when (and how) one dies.
Far worse, the balkanization of our public health system saps our nation’s ability to fight pandemics. If the next pandemic is more lethal than Covid-19, federalism’s legacy of parochialism could be our undoing.