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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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APPENDIX A 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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198 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. REFERENCES American Medical Association, Department of State Legislation, Division of Legislative Activ- ities. 1984. State Health Departments. American Medical Association, Chicago, Ill. American Public Health Association, Association of State and Territorial Health Officials, National Association of County Health Officials, U.S. Conference of Local Health Offi- cials, U.S. Department of Health and Human Services, Public Health Service. 1985. Model Standards: A Guide for Community Preventive Health Services. American Public Health Association, Washington, D.C. American Public Health Association, Health Administration Section. 1984. State Systems of Local Health Department Standards, 1983. American Public Health Association, Washing- ton, D.C. Association of State and Territorial Health Officials Foundation. 1984. Public Health Agencies 1982, vole. 1, 2, and 4. Association of State and Territorial Health Officials Foundation, Washington, D.C. Association of State and Territorial Health Officials, National Public Health Program Reporting System. 1981. Public Health Agencies 1980: A Report on the Expenditures and Activities. Association of State and Territorial Health Officials, National Public Health Reporting System, Washington, D.C. Association of State and Territorial Health Officials Foundation. 1985a. Special Report: Profile of l 983 State Health Agency Data Relevant to the 1990 Objectives for the Nation. Association of State and Territorial Health Officials Foundation, Washington, D.C. Association of State and Territorial Health Officials Foundation. 1985b. Staffs of State Health Agencies. Association of State and Territorial Health Officials Foundation, Washington, D.C. Beyle, T., and P. Dusenbury. 1982. "Health and Human Services Block Grants: The State and Local Dimension." State Government 55~1~:2-13. Bureau of Data Management and Strategy, Health Care Financing Administration, U.S. Department of Health and Human Services. 1985. HCFA Statistics. U.S. Department of Health and Human Services, Washington, D.C. Cameron, C. M., and A. Kobylarz. 1980. "Nonphysician Directors of Local Health Depart- ments: Results of a National Survey." Public Health Reports 95~4~:386-397.

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APPENDIX A 201 Council of State Governments. 1985. The Book of the States, 1984-5. Council of State Govern- ments, Lexington, Ky. Council of State Governments. 1987. The Book of the States, 1986-87, vol. 26. Council of State Governments, Lexington, Ky. DeFriese, G. H., J. S. Hetherington, E. F. Brooks, C. A. Miller, S. C. Jain, F. Kavaler, and J. S. Stein. 1981. "The Program Implications of Administrative Relationships Between Local Health Departments and State and Local Government." American Journal of Public Health 71(10):1109-1115 Department of Health, Commonwealth of Virginia. 1984. The Health Laws of Virginia. The Mitchie Co., Charlottesville, Va. Desonia, R., and K. King. 1985. State Programs of Assistance for the Medically Indigent. Intergovernmental Health Policy Project, Washington, D.C. Desonia, R., J. Luehrs, and G. Brown. 1985. Addressing Health Care for the Indigent: State Initiatives, 1985. The Intergovernmental Health Policy Project, the National Governor's Association, Washington, D.C. Executive Office of the President, Office of Management and Budget. 1987. Budget of the United States Government, Fiscal Year 1988. Government Printing Office, Washington, D.C. Gilbert, Benjamin, Merry-K. Moos, and C. Arden Miller. 1982. "State Level Decision Making for Public Health: The Status of Boards of Health." Journal of Public Health Policy, March, pp. 51-61. Gossert, Daniel J., and C. Arden Miller. 1973. "State Boards of Health, Their Members and Commitments." American Journal of Public Health, June, 63~6~:486-493. Grad, Frank P. 1981. Public Health Law Manual: A Handbook on the Legal Aspects of Public Health Administration and Enforcement. American Public Health Association, Washing- ton, D.C. Hanlon, G., and J. Pickett. 1984. Public Health Administration and Practice. Times Mirror/ Mosby. Haskell, E., and V. Price. 1973. State Environmental Management: Case Studies of Nine States. Praeger Publishers, New York. Mazade, N., T. Lutterman, and R. Glover. 1985a. Funding Sources and Expenditures of State Mental Health Agencies: RevenuelExpenditure Study Results Fiscal Year 1983. National Association of State Mental Health Program Directors, Washington, D.C. Mazade, N., T. Lutterman, and R. Glover. 1985b. Selected State and Federal Government Agency Mental Health Expenditures Incurred on Behalf of Mentally Ill Persons. National Association of State Mental Health Program Directors, Washington, D.C. Miller, C. A., E. F. Brooks, G. H. DeFriese, B. Gilbert, S. C. Jain, and F. Kavaler. 1977. "A Survey of Local Public Health Departments and Their Directors." American Journal of Public Health 67(10):931-939. Miller, C. A., B. Gilbert, D. G. Warren, E. F. Brooks, G. H. DeFriese, S. C. Jain, and F. Kavaler. 1977. "Statutory Authorizations for the Work of Local Health Departments." American Journal of Public Health 67~10~:940-945. Miller, C. Arden, and Merry-K. Moos. 1981. Local Health Departments: Fifteen Case Studies. American Public Health Association, Washington, D.C. Moore, F., and V. Kennedy. 1987. "Analysis of Public Health Workforce." Center for Health and Manpower Policy Studies, University of Texas Health Science Center at Houston, unpublished data prepared for IOM Conference on Education, Training, and the Future of Public Health. National Association of State Mental Health Agencies, Membership List, 1987. National Health Council. 1979. Congress and Health: An Introduction to the Legislative Process and Its Key Participants. National Health Council, Washington, D.C.

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202 APPENDIX A Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services. 1986a. A Review of StateActivities Related to the Public Health Service's Health Promotion and Disease Prevention Objectives for the Nation. U.S. Depart- ment of Health and Human Services, Washington, D.C. Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services. 1986b. The 1990 Health Objectives for the Nation: A Mid- course Review. U.S. Department of Health and Human Services, Washington, D.C. Office of Research and Demonstrations, Health Care Financing Administration, U.S. Depart- ment of Health and Human Services. 1983. The Medicare and Medicaid Data Book, 1983. U.S. Department of Health and Human Services, Washington, D.C. O'Kane, Peggy. 1981. Survey of Health Block Grant Implementation. The Intergovernmental Health Policy Project, Washington, D.C. Omenn, G. S. 1982. "What's Behind Those Block Grants in Health?" New England Journal of Medicine 306(17):1057-1060. Organizational Charts of State Departments of Heath. 1980-1987. Unpublished information collected by the Public Health Foundation for the IOM Committee to Study the Future of Public Health. Public Health Foundation. 1981. Public Health Agencies, 1980. Public Health Foundation, Washington, D.C. Public Health Foundation. 1986a. 1984 Public Health Chartbook. The Public Health Founda- tion, Washington, D.C. Public Health Foundation. 1986b. Public Health Agencies 1984, vole. 1, 2, and 4. The Public Health Foundation, Washington, D.C. Public Health Foundation. 1987. Public Health Agencies 1987. The Public Health Foundation, Washington, D.C. Public Health Service, U.S. Department of Health and Human Services. 1980. Promoting HealthlPreventing Disease: Objectives for the Nation. U.S. Department of Health and Human Services, Washington, D.C. Rabe, Barry G. 1986. Fragmentation and Integration in State Environmental Management. The Conservation Foundation, Washington, D.C. U.S. Department of Commerce. 1986. National Data Book and Guide to Sources: Statistical Abstract of the United States, 106th ed. Government Printing Office, Washington, D.C. U.S. Department of Health and Human Services. 1986. Organizational Chart of the Depart- ment of Health and Human Services. U.S. Department of Health and Human Services, Washington, D.C.