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APPENDIXES
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APPENDIX
A
A Summary of the Public Health System
in the United States
PUBLIC HEALTH AGENCIES
This section summarizes the organization of health agencies, the range of
activities carried out by them, and their use and allocation of resources at
the federal, state, and local levels. When possible, the range of activities
of health agencies are categorized by the functions of public health as out-
lined in Chapter 2: assessment, policy development and leadership, and
assurance of access to environmental, educational, and personal health
services.
FEDERAL
The federal government plays a large role in the public health system in the
country. It surveys the population's health status and health needs, sets
policies and standards, passes laws and regulations, supports biomedical and
health services research, helps finance and sometimes delivers personal
health services, provides technical assistance and resources to state and local
health systems, provides protection against international health threats, and
supports international efforts toward global health. The federal government
does all of these mainly through two delegated powers: the power to regulate
interstate commerce and the power to tax and spend for the general welfare.
The federal government's regulatory activities, such as labeling hazardous
substances, are based in the power to regulate interstate commerce. Its
service-oriented programs, such as the cleanup of hazardous substances or
financing personal health services through Medicaid and Medicare pro
165
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166
APPENDIX A
grams, are based in its power to tax and spend for the general welfare.
(Grad, 1981)
At present, the main federal unit with responsibility for public health is
the United States Public Health Service in the Department of Health and
Human Services. The second major unit is the Health Care Financing
Administration, also in the Department of Health and Human Services.
Other federal departments also have agencies with responsibilities for
health, such as the Food and Nutrition Service in the Department of Agricul-
ture, the Office of Special Education and Rehabilitative Services of the
Department of Education, and the Environmental Protection Agency. Their
participation will be discussed in a later section of this chapter.
Leadership
The Secretary of the Department of Health and Human Services is chosen
by the President of the United States and sits in his Cabinet. The head of the
Public Health Service, the Assistant Secretary for Health, is also appointed
by the President. The Surgeon General, who is also appointed by the
President, acts as an adviser to the Secretary and the Assistant Secretary.
Organization
The United States Public Health Service includes the (1) Centers for
Disease Control; (2) the National Institutes of Health; (3) the Food and
Drug Administration; (4) the Health Resources and Services Administra-
tion; (5) the Alcohol, Drug Abuse, and Mental Health Administration; and
(6) the Agency for Toxic Substances and Disease Registry (Figure A.1~.
Additionally, several offices relating directly to the Assistant Secretary for
Health deal with public health issues, such as the Office of Health Promotion
and Disease Prevention and the Office of Planning and Evaluation. These
offices are concerned with management; health policy, research, and statis-
tics; planning and evaluation; intergovernmental affairs; health promotion;
and other special concerns. (Hanlon and Pickett, 1984)
The Centers for Disease Control, the main assessment and epidemiologic
unit for the nation, directly serves the population as well as providing
technical assistance to states and localities. The National Center for Health
Statistics within the Centers for Disease Control is the main authority for
collecting, analyzing, and disseminating health data. The Agency for Toxic
Substances and Disease Registry, also an assessment unit, focuses on envi-
ronmentally related diseases. The National Institutes of Health, the primary
research arm of the government, both conducts research and supports
research projects across the nation. The Food and Drug Administration
directly tests and assesses safety of food, drugs, and a wide variety of
consumer goods and sets standards for safe use of these items. The Health
Resources and Services Administration is primarily concerned with re
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APPENDIX A
167
SECRETARY
UNDER SECRETARY
CHIEF OF STAFF
_
, I 1 1 I ~1
OFFICE OF HUMAN DEVELOPMENT
SERVICES
Administration on Aging
Administration for Children.
Youth, and Families
Administration for
Native Americans
Administration on
Developmental Disabilities
Office of Program
Coordination and Review
HEALTH CARE FINANCING
ADMINISTRATION
PUBLIC HEALTH SERVICE
Centers for Disease Control
Food and Drug Administration
Health Resources and
Services Administration
National Institutes of
Health
Alcohol, Drug Abuse, and Mental
Health Administration
Agency for Toxic Substances
and Disease Registry
SOCIAL SECURITY
ADMINISTRATION
FIGURE A.1 Department of Health and Human Services organization chart.
sources development and health manpower. The Alcohol, Drug Abuse, and
Mental Health Administration concentrates on developing programs and
setting standards in these areas. Both the Health Resources and Services
Administration and the Alcohol, Drug Abuse, and Mental Health Adminis-
tration establish and support health services through grants and contracts to
state and local government agencies, private health care institutions, and
individuals. They also act as coordinators and technical assistants to recip-
ients of contracts and grants. Sometimes these agencies provide services,
such as the Indian Health Service in the Health Resources and Services
Administration, through which the government provides health care ser-
vices to Native Americans and Eskimos. (Hanlon and Pickett, 1984)
The other major division of the Department of Health and Human Ser-
vices concerned with public health activities is the Health Care Financing
Administration, which operates the Medicare and Medicaid programs. The
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168
APPENDIX A
federal government directly finances health services for elderly Americans
through the Medicare program and provides grants to the states through the
Medicaid program to assist them in financing health services for poor Ameri-
cans. A large portion of Medicaid money also goes to finance long-term care
for the elderly.
Other operating divisions of the Department of Health and Human Ser-
vices are primarily oriented toward human and social services. These offices,
although not designated specifically for health, conduct many health-related
activities. For example, the Office of Human Development Services houses
the Administration on Aging and the Administration on Developmental
Disabilities, both of which are involved in long-term health care issues.
(Figure A.1; Hanlon and Pickett, 1984)
The Department of Health and Human Services also operates regional
offices in Boston, New York, Philadelphia, Atlanta, Chicago, Dallas, Kan-
sas City, Denver, San Francisco, and Seattle, which are involved in program
development and provide technical assistance to states and local areas within
their region. They also oversee programs contracted from the federal gov-
ernment to the states.
Activities
The federal government is involved in each of the public health functions
outlined in Chapter 2. The examples of each type of activity are numerous
and occur throughout the branches of the Public Health Service and the
Health Care Financing Administration, as well as in related government
agencies. For example, assessment is a major responsibility of the Centers
for Disease Control and the National Center for Health Statistics, but also
takes place in the Health Resources Administration, which collects data on
health manpower; the Food and Drug Administration, which inspects foods,
drugs, and other products; the Office of Disease Prevention and Health
Promotion, which collects statistics on prevention activities and the popula-
tion's health status; the National Institute of Mental Health, which collects
data on inpatient and outpatient mental health services; and the Health Care
Financing Administration, which collects information on use of health ser-
vices. Biological research is mainly the task of the National Institutes of
Health, and epidemiologic research is mainly the task of the Centers for
Disease Control.
The National Center for Health Services Research, under the Office of the
Assistant Secretary for Health, is the main authority for policy and health
services research. But policy research and health services research can be
sponsored by any of the many offices. The Health Care Financing Adminis-
tration, for example, has an office of research and development. Policy-
setting and providing technical assistance take place in nearly all federally
conducted programs.
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APPENDIX A
169
Financing personal and public health services is mainly the task of the
Health Care Financing Administration's Medicare and Medicaid offices, but
grants for specific services are administered throughout the Department of
Health and Human Services. Personal health services are directly delivered
by the federal government under the auspices of the Health Resources and
Services Administration in the Indian Health Service, but also by the Vet-
eran's Administration and the Department of Defense in military clinics and
hospitals.
Overall, federal activities fall into two major categories: those that are
conducted directly by the federal government assessment, policy-making,
resources development, knowledge transfer, financing, and some delivery of
personal health care and those that are contracted by the federal govern-
ment to states, localities, and private organizations the majority of direct
service programs. (Hanlon and Pickett, 1984)
The major portion of the federal government's health business is con-
ducted through contracts and grants to states, localities, and private pro-
viders and organizations. The federal government acts through financing
intergovernmental and interorganizational contracts to encourage various
public health initiatives, convening participants around an issue, coordinat-
ing activities, and developing state and local provider contracts. In return for
federal funds, states, localities, and private organizations must follow the
federal standards and policies set in the contract. Thus in many programs,
the federal government takes an oversight, policy-setting, and technical
assistance role, rather than a direct provider role. Federal contracts can take
the form of seed money for researching and developing new programs, such
as Community Mental Health Centers, or they can be support for ongoing
activities, such as the Early Periodic Screening, Detection, and Treatment
Program. Contracts can be made with agencies to operate specific public
health programs or to support general agency activities. Contracts can also
be made with health care providers, such as nursing homes or home health
agencies, for directly delivering personal health services. Contracts with
local areas and providers may be operated through the states or be made
directly with the local areas and private sector.
Most contracts to states and localities were initially offered as "categori-
cal" grants, focusing on particular health issues or populations, for example,
research training grants for education, nutrition information programs, sub-
stance abuse and mental health programs, and family planning programs. In
the early 1980s, the federal administration grouped numerous categorical
grants to states into four major "block" grants: one in preventive health, one
in maternal and child health, one in primary care, and one in alcohol, drug
abuse, and mental health. However, a number of categorical aid programs
remain, both as grants to states and localities and to private providers.
(Hanlon and Pickett, 1984)
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70
APPENDIX A
Resources
In 1986, the budget for the Public Health Service totaled about $10 billion
and is projected to exceed $12 billion by 1988. The budget of the Depart-
ment of Health and Human Services was $353 billion in 1986. (This figure
includes the Public Health Service budget.) A large portion of the depart-
ment's budget, more than $197 billion, was allotted for the Social Security
Program. Another large portion, about $95 billion, was allotted to the
Health Care Financing Administration for the Medicare and Medicaid pro-
grams. (Executive Office of the President, Office of Management and Bud-
get, 1987) In 1984, about $1 billion of the total departmental budget was
spent in contracts to state health agencies; another half billion was contrac-
ted directly to local areas for health programs. (See Figures A.2 and A.3;
Public Health Foundation, 1984)
To put federal health spending in perspective, the Health Care Financing
Administration reports thatiederal expenditures in health were $112 billion
in 1984; public expenditures (all government) in health care were $160
Other
Public Health Service
34.0 billion
10.0 billion
Family Support Administration and
Human Development Services 18.5 billion
Health Care Financing Administration 95.0 billion
Social Security Administration 197.0 billion
Total
356.0 billion
FIGURE A.2 Expenditures of the Department of Health and Human Services, 1986.
SOURCE: Office of Management and Budget, 1987.
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APPENDIX A
N
171
Office of Assistant Secretary for
Health and General Administration 1.0 billion
Alcohol, Drug Abuse, Mental
Health Administration
1.0 billion
Centers for Disease Control 0.5 billion
Health Resources and Services
Administration
Food and Drug Administration
2.0 billion
0.5 billion
National Institutes for Health 5.0 billion
Total
10.0 billion
FIGURE A.3 Expenditures of U.S. Public Health Service, 1986. SOURCE: Office of Manage-
ment and Budget, 1987.
billion; and nationalhealth expenditures (including both public expenditures
and private funds for health care and medical care) were in the range of $387
billion. (Bureau of Data Management and Strategy, Health Care Financing
Administration, 1985) Federal expenditures per person were about $460
(U.S. Department of Commerce, 1986), and national health expenditures
per person were $1,580. (Bureau of Data Management and Strategy, Health
Care Financing Administration, U.S. Department of Health and Human
Services, 1985)
Federal spending in health and national spending on health have been
subjects of great controversy in the 1980s. Federal spending on health
increased dramatically between the 1960s and 1980s, to the extent of several
hundred percent in some programs. (Bureau of Data Management and
Strategy, Health Care Financing Administration, U.S. Department of
Health and Human Services, 1985) Many new programs were also initiated
in the 1960s. Cutbacks in federal health spending have been a major goal of
the federal administration in the 1980s. For example, the block grants
initiated in 1981 included a 25 percent cut in funding to states for the
categorical programs included. (Omenn, 1982) (A portion of price cutbacks
have since been restored.) Remaining categorical grants were also cut back.
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72
APPENDIX A
Although federal spending in health continues to increase, it is doing so at a
slower pace (U.S. Department of Commerce, 1986)
In terms of personnel, more than 128,000 people are employed by the
Department of Health and Human Services. Numerous others are employed
in health-related positions in other agencies such as the Department of the
Interior and the Environmental Protection Agency.
STATE
States are the principal governmental entity responsible for protecting the
public's health in the United States. They conduct a wide range of activities
in health. State health agencies collect and analyze information; conduct
inspections; plan; set policies and standards; carry out national and state
mandates; manage and oversee environmental, educational, and personal
health services; and assure access to health care for underserved residents;
they are involved in resources development; and they respond to health
hazards and crises. (Hanlon and Pickett, 1984; Public Health Foundation,
1986b) States carry out most of their responsibilities through their police
power, the power "to enact and enforce laws to protect and promote the
health, safety, morals, order, peace, comfort, and general welfare of the
people." (Grad, 1981) In the tenth amendment of the U.S. Constitution,
states and the people are designated as the repository of all government
powers not specifically designated to the federal government. States, as
sovereign governments, derive plenary and inherent power to govern from
their people. As guardians of the public interest, states have inherent power
to act to protect citizens of the state for the good of the entire citizenry.
Massachusetts, the first state to establish a State Board of Health, did so "in
the interests of health and life among the citizens of the Commonwealth."
(Hanlon and Pickett, 1984) States also have the power to delegate agencies
with authority to carry out activities in their interest. As phrased in a state
law of Virginia,
The General Assembly finds that the protection, improvement and preservation of
the public health and of the environment are essential to the general welfare of the
citizens of the Commonwealth. For this reason, the State Board of Health and the
State Health Commissioner, assisted by the State Department of Health, shall
administer and provide a comprehensive program of preventive, curative, restora-
tive, and environmental health services, educate the citizenry in health and environ-
mental matters, develop and implement health resource plans, collect and preserve
vital records and health statistics, assist in research, and abate hazards and nuisances
to the health and to the environment, both emergency and otherwise, thereby
improving the quality of life in the Commonwealth. (Department of Health, Com-
monwealth of Virginia, 1984)
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APPENDIX A
173
Leadership
There are 55 state health agencies in the country (the 50 states plus the
District of Columbia, Guam, Puerto Rico, American Samoa, and the U.S.
Virgin Islands). Each state agency is directed by a health commissioner or
secretary of health. Each also has a state health officer, who is the top public
sector medical authority in the state. In many states, the state health officer
is the director of the state health agency. In some states, the state health
officer works for the director, who is an administrator of a larger agency or
department. State health officers are appointed either by the governor, the
State Board of Health, or an agency head. (Council of State Governments,
1985~. Most states require the state health officer to have a degree in
medicine, and some require a degree in public health or public health
experience. (Table A.1; American Medical Association, Department of
State Legislation, 1984) The average term of a state health officer is about 2
years. (Gilbert et al., 1982~. The annual salary of state health officers varies
substantially among states. In 1986, five states paid more than $80,000 per
annum and eight states paid less than $50,000. (Table A.2; Council of State
Governments, 1987)
Twenty-four states have boards of health. In general, boards are responsi-
ble for policy-making and for spending. The boards' relationships to the
health officers vary. In most states, the health officer reports to the board. In
some, the health officer is a board member. More than 90 percent of the
appointments to boards of health are made by the governor. The remainder
are appointed by professional associations or by the state health agency
director. About three-quarters of the members of state boards of health are
health professionals, and, among these, most are physicians. The average
term of a board member is 4 years. (Gilbert et al., 1982)
Organization
State health agencies are organized in one of two models: as a free-
standing independent agency responsible directly to the governor or the
Board of Health or as a component of a superagency. Of the 55 state
agencies, 33 are independent agencies and 22 are divisions of superagencies.
(Public Health Foundation, 1986b) In 1980, 34 were independent and 21
were superagencies. (See Table A.3; Association of State and Territorial
Health Officials, 1981)
The scope of responsibilities of independent agencies and superagencies
varies. Fourteen state health departments are also the main environmental
agency in their state; fifteen are the mental health agency; and eleven are
also the state Medicaid agency. (Public Health Foundation, 1986b) A few
states have changed organizational responsibilities since 1980. (Table A.3;
Association of State and Territorial Health Officials, 1981)
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92
APPENDIX A
initiatives carried out by the public health service and others originate with
these committees.
In the federal executive branch, numerous agencies other than the Public
Health Service conduct health-related activities. These agencies are con-
cerned with the health of special populations or with special problems,
including the medical divisions of the army and navy, the Veteran's Adminis-
tration, the Bureau of Indian Affairs, the Agricultural Extension Service,
the Department of Education, the Occupational Health and Safety Admin-
istration, the Federal Trade Commission, the Bureau of Labor Standards,
the Bureau of Mines, the Maritime Commission, many bureaus within the
Department of Agriculture, and the Bureau of Employees' Compensation.
Other agencies are concerned with international health interests, including
the Agency for International Development and the Department of Defense.
(Hanlon and Pickettt, 1984)
In the representative areas of environment, mental health, and social
services, there are programs both within the Department of Health and
Human Services and outside of that department.
Environmental programs are mainly handled by the Environmental Pro-
tection Agency and by the Agricultural Department. These agencies con-
duct assessment activities, develop policies and standards, provide direct
services and technical assistance to states and localities, and conduct re-
search. The Environmental Protection Agency has programs in air pollution
and water pollution control, hazardous waste cleanup, control of pesticides,
radiation protection, and research. (Haskell and Price, 1973) Some of these
programs are direct federal activities, and some provide assistance to state
environmental departments and state health agencies. The Agricultural
Department has services for food safety and inspection, sanitation, and
assessment of both plant and animal diseases. These services are predomi-
nantly federally run. The federal government spent more than $3.5 billion on
environmental programs in 1986. (Executive Office of the President, Office
of Management and Budget, 1987)
The majority of federal mental health programs are sponsored by the
Public Health Service in the Alcohol, Drug Abuse, and Mental Health
Administration. This administration predominantly conducts its programs
through grants and contracts to states, localities, and private organizations.
Some additional mental health programs are conducted through other de-
partments, for example, Department of Education programs for the hand-
icapped. The federal government is also involved in directly financing men-
tal health care through the Medicare and Medicaid programs and in directly
providing mental health care through the operation of a mental health
hospital. The federal government spent more than $3 billion on mental
health programs and care in 1983 in contracts and grants and in financing
care for individuals. (Mazade et al., 1985a)
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APPENDIX A
193
Programs devoted to social services and the welfare of citizens are within
the Department of Health and Human Services in the Office of Human
Development Services and the Family Support Service. These programs are
involved in assessment of population needs, policy development, providing
technical assistance to the states, and in providing direct services to citizens.
Agencies include the Administrations on Aging; Native Americans; Chil-
dren, Youth and Families; Refugees; and the Developmentally Disabled.
Examples of programs in personal health services and social services outside
of the Department of Health and Human Services are numerous. The
Bureau of Nutrition and Home Economics of the Department of Agriculture
works with the agricultural extension service to improve the nutrition of rural
populations. The Department of Agriculture also runs the food and nutri-
tion service, including both the food stamp program and the supplemental
nutrition program for women, infants, and children. The Department of
Defense has hospitals and clinics for military and military dependents.
The Veteran's Administration runs hospitals and nursing homes. The Bu-
reau of Mines in the Department of the Interior conducts health, sanitation,
and safety programs for employees of the mining industry. The Department
of Education promotes programs of health education and health safety,
engages in screening and medical examinations of students and teachers, and
administers a grant program for vocational education in health. (Hanlon and
Pickett, 1984) Some of these programs relate to social service agencies in the
states, some to educational departments, and some to health departments.
Many provide direct services or assistance to consumers.
Federal spending on personal social and health services is difficult to
assess. In 1986 the Office of Human Development Services spent about $5
billion. The Family Support Administration spent about $13 billion. Pro-
grams outside the Department of Health and Human Services added consid-
erably to the total spent on personal medical and social services, for example
the budget for the Veteran's Administration Medical Care Services was $9
billion in 1986. The Occupational Safety and Health Administration had a
budget of $200,000. The budget of the Food and Nutrition Service of the
Department of Agriculture was more than $18 billion. The cost of the
supplemental nutrition service for women, infants, and children was more
than $1.6 billion in 1986. In many states, federally funded nutrition services
are the largest public health program. In addition, many personal social
and health services are financed by the Health Care Financing Adminis-
tration and the Social Security Administration, and by programs within
the other departments and agencies. In 1986 the Health Care Financing
Administration spent more than $70 billion in Medicare expenditures
and nearly $25 billion in Medicaid expenditures. That same year the Social
Security Administration spent about $10 billion on supplemental
security income, which can be used to cover long-term health benefits.
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194
APPENDIX A
(Executive Office of the President, Office of Management and Budget,
1987)
Nongovernmental
In the private sector, the national organizations with interests in health are
almost too numerous to list. There are professional membership organiza-
tions for almost every type of health professional and every type of health
care organization. Examples include the American Medical Association, the
American Nurse's Association, the National Social Workers Association,
the American Public Health Association, the National Association of Com-
munity Health Centers, the American Hospital Association, and the Asso-
ciation of State Mental Health Agency Directors. Members in these organi-
zations come from both the private and the public sectors. These groups
generally serve for members to exchange knowledge and to promote poli-
cies. Sometimes they are involved in lobbying Congress for changes in
national health policies and regulations, changes in programs, and support
for research. For example, the American Medical Association has been
active in supporting research related to the health effects of smoking and in
antismoking campaigns. The American Public Health Association has taken
political positions on nuclear policy and Central American politics, as well as
campaign for legislation and education on many health problems such as
smoking, teen pregnancy, and injury.
There are also numerous nonprofit associations on the national level that
are organized around particular health problems or issues, rather than
around a professional discipline. Examples include the American Heart
Association, the American Cancer Society, the Alzheimer's Disease and
Related Disorders Association, and the American Diabetes Association.
These associations also provide arenas for information exchange and policy
development, and they sometimes sponsor research in their area of concern.
They are also often involved in lobbying for new policies, activities, and the
development of resources. For example, the American Cancer Society has
been integral in developing resources for cancer research and for promoting
antismoking campaigns.
There are also national organizations of citizens focused around health
issues or concerned about health in general. Groups include both profes-
sionals and consumers and representatives from public agencies and from
private providers. Examples include Dissatisfied Parents Together, Alco-
holics Anonymous, National Association of Retarded Citizens, National
Consumers League, and Gay Men's Health Crisis. These groups are gener-
ally involved in information exchange, coalition building, and lobbying.
They can be the main force in starting new programs. For example, the Gay
Men's Health Crisis has played a central role in starting up community health
services for AIDS victims in New York City. The National Association of
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APPENDIX A
195
Retarded Citizens played a central role in securing resources for community
care and health care for mentally retarded citizens across the country.
Finally, at the national level, there are foundations that support health
research projects and demonstrations of new health services, including The
Robert Wood Johnson Foundation, Pew Memorial Trust, Rockefeller Foun-
dation, Kellogg Foundation, Commonwealth Fund, and The Rosenwald
Foundation. They can act much like the federal government in providing
grants to local areas for health programs and in supporting research. These
foundations can play a strong role in assisting information and policy devel-
opment, and in providing services in a local area. In 1984, about $10.4 billion
were given to health and hospitals in private philanthropy, and about $8
billion were given to social welfare projects. (U.S. Department of Com-
merce, 1986) A few examples of programs supported by foundations include
health care for homeless citizens in 16 cities supported by Pew Memorial
Trust, the promulgation of community services for AIDS victims supported
by Robert Wood Johnson, and research on access to health care, also by
Robert Wood Johnson.
All of these types of private groups can be vital influences in the develop-
ment of public health policy on the national level and in the carrying out of
public health programs, both in national and local settings.
It should be kept in mind that national resources expended on health
include the activities of all of these associations and organizations. The
nation spent in the range of $387 billion on health and medical care in 1984.
(Bureau of Data Management and Strategy, Health Care Financing Admin-
istration, U.S. Department of Health and Human Services, 1985) This
figure does not, however, include private grants for health services, member-
ship dues, expenditures of agencies other than health agencies, and tremen-
dous amounts of volunteer time. Public health manpower is also present in
all of these arenas. There are approximately 62,000 graduates of public
health schools and public health programs in this country (Moore and
Kennedy, 1987~. And there are about 5.6 million health professionals in the
country, including about 1.8 million nurses and some 500,000 physicians.
(U.S. Department of Commerce, 1986~. Some portion of these individuals
work in public agencies, many work in medical care, and some work in
nonprofit associations. Taken together, they represent the national public
health system's workforce.
STATE
Governmental
On the state level, government, public agencies, and private groups are
also active in the public health system. Many state legislatures have commit
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196
APPENDIX A
tees with interests in health issues. And several states have governor-
appointed task forces on particular health issues. For example, 22 state
legislatures introduced bills concerning access to health care for the medi-
cally indigent population in 1984; 20 states organized legislative or guber-
natorial study commissions on the issue in 1984. (Desonia and King, 1985)
These groups can be the principal public health policymakers in a state. The
designation, involvement, and activity of these committees and task forces
vary from state to state.
States can have several agencies engaged in activities related to public
health, including environmental agencies; social service and welfare agen-
cies; agencies for human development, for aging, and for the developmen-
tally disabled; mental health agencies; Medicaid agencies; education depart-
ments; housing authorities; and traffic and highway departments. The exact
array of agencies in a given state varies, as does the involvement of the
agencies in health issues. In the examples of the environment, social ser-
vices, and mental health, states have an array of agencies that vary as much
as their health agencies. In some states, environmental, social service, and
mental health agencies are combined with the state health department, and
in some states they are separate agencies. In all states, there are programs in
these areas that overlap with those of the health department, regardless of
whether the agencies are combined.
A majority of the states have independent environmental agencies. These
agencies conduct assessment and address environmental hazards. They can
be devoted to single environmental issues water safety, hazardous waste
control, fish and wildlife, air pollution control-or they can be environmen-
tal superagencies. Nearly all of the states also have units within their health
departments devoted to environmental health concerns, such as sanitation,
inspection, water supply, pollution control, and sometimes occupational
safety and hazardous materials control; and most state health agencies take
the lead responsibility in a state for one or more environmental health
services. In some states, these functions are combined. In 11 states, the state
health agency is the principal "lead" environmental agency. In 28, another
agency fills that function. (In 5 states there is no officially designated lead
environmental agency.) In a few of the states in which the health agency is
the lead environmental agency, there are additional environmental agencies
that coordinate with the health agency. For example, the health department
might deal with water supply safety, and a separate agency might deal with
taxies and hazardous materials, environmental factors that would affect the
water supply. Some states interpret environmental issues as intrinsically
related to health, as the cleanliness of the environment directly affects
health. Some states interpret environmental activities as conservation of
resources. Many states interpret environmental issues as both and separate
them between agencies.
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197
In any situation, the activities of environmental agencies and health
agencies often overlap. Forty-four state health agencies have lead respon-
sibility for some environmental health programs, even though only 11 are
the lead environmental agency. Thirty-two state agencies share respon-
sibility for some environmental programs with another agency, and 26 play a
supporting role to another agency that has the lead responsibility for pro-
grams. (Public Health Foundation, 1986b; Haskell and Price, 1973)
In 15 states, the state health agency is also the lead mental health agency
for the state. (Public Health Foundation, 1986b) In 14 states, the mental
health agency is housed within the health and human services superagency;
in 5, it is in an independent health agency; in 18, the mental health agency is
independent; and in 14, the mental health agency is part of the welfare or
social services agency. (National Association of State Mental Health Agen-
cies, 1987~. Many states also have separate agencies for developmental
disabilities, mental retardation, and substance abuse control.
There can be a good deal of overlap between state health agency concerns
and mental health agency concerns. State mental health agencies handle
programs of both a public health nature, such as prevention of mental illness,
alcoholism and drug abuse prevention, research, and manpower training, as
well as personal health services such as treatment of mental illness, rehabili-
tation for substance abusers, and services for the mentally retarded and
developmentally disabled. In 44 states, public health agencies report that
they operate programs for the mentally retarded and developmentally dis-
abled; 37 operate mental health programs; 33 have alcohol abuse programs;
and 29 have drug abuse programs. (Public Health Foundation, 1986b) All
states either operate services for or finance inpatient mental health care. In a
few, inpatient mental health, mental disability, and substance abuse services
are operated or financed by the state health agency. (Mazade et al., 1985b;
Public Health Foundation, 1986b) In each state there is some overlap be-
tween public health and public mental health.
In nearly half of the states, the health agency and the social services agency
are combined to form superagencies for human services, much like the
federal Department of Health and Human Services. These agencies handle
social services for the aged; for children, youth, and families; for adolescents;
for the developmentally disabled; and sometimes for particular social prob-
lems, such as alcoholism and drug abuse-as well as health services for these
groups. The remainder of the states have independent social services or
welfare agencies. In many states, social services and health services can
overlap in areas such as alcohol and drug abuse rehabilitation and mental
health or family services and maternal and child health care. Some programs
are essentially both social services and personal health services.
Nowhere is the overlap between health and social services more apparent
than in the Medicaid program. Many states view Medicaid as a social
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APPENDIX A
services program, providing services for disadvantaged citizens. But a few
states view Medicaid as a health program, financing health care services. In
14 of the states, the state Medicaid agency is housed within the health and
human services superagency. In 27, the Medicaid agency is in an indepen-
dent welfare or social service agency or in a state welfare agency separate
from the health and human services superagency. In 5 states, Medicaid is
handled by the independent state health agency, and in 3, Medicaid is a
separate agency. (Office of Research and Demonstrations, Health Care
Financing Administration, U.S. Department of Health and Human Ser-
vices, 1983) In any of these cases, there is considerable influence in both
directions between public health policy and Medicaid policy. The operation
of health programs and the financing of health services are connected,
particularly in states in which the state health agency concentrates its efforts
on personal health services. In most states, the state Medicaid budget is
equal to or far exceeds the public health budget. States spent between $9
million and $370 million on their public health programs in 1980, and
between $14 million and $2.7 billion for Medicaid in 1980. (Association of
State and Territorial Health Officials, National Public Health Reporting
System, 1981; Office of Research and Demonstrations, Health Care Financ-
ing Administration, U.S. Department of Health and Human Services, 1983)
Nongovernmental
In the private sector, there are many state-level professional associations,
nonprofit associations, and consumer organizations that parallel the national
organizations described above. Many are state factions of the national orga-
nizations and serve to exchange information, promote policies, and lobby on
the state level. There are state medical associations, state nurse's associa-
tions, social worker's associations, and public health associations, to name a
few.
In addition to state members of national organizations, there are private
organizations involved in the public health system that are more visible on
the state level. Some states have business coalitions that are involved in
health promotion programs at the worksite. The Washington Business
Group on Health in Washington, D.C., is an example of this type of organi-
zation. Other states have a single major employer that is involved in health
promotion. Johnson and Johnson runs a popular "fit for life" program for its
employees. Some states have medical schools, public health schools, and
nursing schools Johns Hopkins, Harvard, the University of Washington,
the University of California-that are important influences in the public
health system in directing policy, providing services, and conducting re-
search. Private health care providers, such as major hospital systems, can
also be visible influences in the public health system at the state level. And
finally, the media can play a large role in focusing issues and providing
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APPENDIX A
199
information on health at the state level. Many papers, such as The Washing-
ton Post, have special health sections written for consumers.
LOCAL
Governmental
On the local level, government, local agencies, and private organizations
can also be central to the public health system. County supervisors, alder-
men (freeholders, selectmen), and mayors can direct the public health
system in the same manner that the legislature and the governor direct public
health issues and policies on the state level. Local government can also
convene task forces and meetings around particular issues.
Local areas can also have other public agencies active in the public health
system. All local areas have boards of education, which may be involved in
school health and child and adolescent health issues. And they have police
and fire departments, which may be active in emergency care.
Local areas may also have agencies involved in environmental protection,
social services, and mental health. These agencies vary as significantly from
area to area as local health agencies. They can be divisions of the state
agencies, or independent. Or they can be district offices. In addition, these
agencies can be combined with the health department or separate from the
health department, as on the state level. And their organization may parallel
state organization, or it may not. Regardless of local organization, environ-
mental, social service, and mental health public agencies have concerns and
conduct activities which overlap with those of the local health agency in the
same manner that concerns of state agencies overlap. The local health
department may monitor an individual's water supply, while a local environ-
mental agency monitors industrial or agricultural water supplies. The local
health department may have a substance abuse prevention program, while
inpatient mental health services are provided by another agency. And the
local health department may provide maternal and child health services to
families that go to the welfare agency to apply for Medicaid.
Nongovernmental
Private organizations can also have a powerful influence on a local public
health system. In the local arena, the private health care provider becomes
particularly visible. In many areas, the physicians working at the local health
department, or even the local health officer, may be a private practitioner.
Or a private clinic or hospital may be the principal provider of services for a
particular area. As on the state and national levels, the media, consumer
groups, and professional organizations can also have a major influence on
the public health system in a local area. The media, consumers, and profes
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200
APPENDIX A
signals can draw attention to issues; they can lobby local government for
changes in policy; and they can be sources for information.
CONCLUSION
It should be noted that the public health system, as divided above by
national, state, and local settings, is not necessarily that static. There are
many channels for information and coordinated activity between national,
state, and local levels in both the public and private sectors, just as there is
exchange of information and coordination of activity between the health
agencies, other agencies, and private actors. The system is both intergovern-
mental and interorganizational. The amount of interchange and cooperation
between government levels and the public and private spheres, however,
differs between settings and across issues.
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Representative terms from entire chapter:
state health
