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4 An Assessment of the Current Public Health System: A Shattered Vision The following chapter describes the current state of public health as observed by the committee during the course of its study. The committee viewed public health on a broad scale, considering the participation of all of the groups described in Chapter 2 which fulfill the mission of public health: government and government agencies, private providers, and voluntary organizations. This broad level is termed the public health system* by the committee. Within this group, the committee focused on the role and activities of the public health agencies, the government entities that focus the mission of public health. Other participants were considered primarily in relation to the public health agencies. Within the United States, the role of public health agencies and their relationships with other participants in the system vary tremendously. These variations reflect tremendous differences in the fundamental concept of the definition and mission of public health across the country. "Public health" in the United States is defined not only by the scope of health problems and their interventions in each area, but also by the values * In the United States, government responsibility to protect the public's health is represented by public health agencies, state and local health departments, and by the federal Department of Health and Human Services. Thepublic health system in the United States includes a wide array of other public agencies, such as environmental, occupational safety, mental health, develop- mental disability, and social service agencies at national, state, and local levels. It also includes national, state, and local private organizations and providers, such as health professional associations, citizen advocacy groups, the media, community health centers, and research foundations. Together, these participants in the system fulfill the mission of public health. The public health agencies, as the governmental representative of public health, focus this mission. 73

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74 THE FUTURE OF PUBLIC HEALTH Americans have about the importance of a particular problem and the necessity of addressing that problem with public activities. The current public health system is shaped by its goals, by the health problems to be solved, and by the political system within which it functions. Because public health problems are often addressed on a state and local rather than a national scale, goals are set within different political systems. Different communities have different health problems and they have appre- ciably different political and social organizations and values. So, public health systems in these communities vary widely and offer widely differing public health services. Viewed from a national perspective, the national public health system is a scene of tremendous variety and disarray as different communities work out different solutions to public health problems. This chapter describes how the committee conducted its study of the national public health system and then describes the committee's observa- tions of the system in specific areas it visited. Anecdotes from local areas are used as representative data, reflecting trends observed on a national level from published data, literature, and committee experience. Major charac- teristics of the entire system are briefly summarized in this chapter. A more detailed description of the public health system can be found in Appendix A to this report. VIEWING THE SYSTEM For this study, the committee decided that its conclusions about the current public health system would benefit from firsthand observation that could augment analysis of more inclusive information summarized in this chapter and in Appendix A. Therefore, it made site visits to the state capitals and several local areas in California, Mississippi, New Jersey, South Dakota, Washington, and West Virginia. In each state committee members and staff spoke with hundreds of citizens who work in and are served by the public health system. The committee also held four open meetings in Las Vegas, Boston, New Orleans, and Chicago at which several hundred citizens and public health practitioners spoke. The committee realized that not all variations in the country could possi- bly be examined in site visits. However, the committee felt that a careful selection of sites in six states would present sufficient variety to illustrate the range of health problems and public health activities that exist across the nation. The areas visited within the states were chosen to reflect a variety of geographical locations, urban-rural mix, health problems, population mix and economic status, public health agency organization, and array of public health services. (See Appendix D for a fuller description of the selection process and the plan for the site visits.) Individual sites were treated as

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AN ASSESSMENT OF THE CURRENT PUB f IC HEALTH SYSTEM 75 illustrative rather than representative of public health practice in the United States or as exhaustive case studies. But the committee believes that these illustrations illuminate fundamental issues for the entire system. Among the six states, population density ranged from one of the most densely populated states to one of the least. In one, the proportion of urban dwellers was 16 percent; in another, 95 percent. Per capita personal income in the states ranged from $8,857 to $15,182. Percentage of high school graduates in the state varied from 55 percent to 77 percent, and unemploy- ment from 6.2 percent to 13 percent. The states had different percentages of minority groups, including blacks, Hispanics, Asians, and Native Ameri- cans, as well as populations of illegal immigrants. State and local health expenditures per person were as low as $72, and as high as $172. Physicians per 100,000 population ranged from 107 to 230. (U.S. Department of Commerce, 1986) In some states, private health resources and services were abundant, and in some they were very scarce. Some state governments put a great deal of emphasis on carrying out the public health mission, and some put very little emphasis on it. At each site, committee members and committee staff spoke with state and local health officers; state and local health department directors and program administrators; state and local environmental, social service, and mental health agency personnel; representatives of local and state govern- ment; representatives of hospital, medical, and nursing professional associa- tions and of citizen organizations; health professionals; administrators and board members in private and public hospitals and clinics; journalists; and professors of medicine and of public health. The committee conducted a total of more than 350 interviews. Interviews focused mainly on health problems identified by those inter- viewed and the means by which the system was successfully or unsuccessfully handling these problems. Identified problems included teenage pregnancy, medical care for indigent populations, safe water supply, the disposal of hazardous materials, AIDS, alcoholism, mental health, prenatal care, smoking prevention, access to medical care, sexually transmitted diseases, infant mortality, home health, long-term care, Alzheimer's disease, injuries, malpractice, childhood vaccines, substance abuse, asbestos, radiation con- trol, and dental health. Many views of public health were expressed, ranging from "it affects everybody" to "it's whatever the market won't do." Descrip- tions of public health agencies varied from "the public health department is the champion/guardian of the public's health" to "I don't know what they do" and "public health professionals are 'also fans' in the medical profession." Federal health officials were also interviewed during the study. And a subgroup of the committee made a visit to Toronto, Canada, to discuss the Canadian public health system with several health officials and health pro- fessionals.

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76 THE FUTURE OF PUBLIC HEALTH Of the four meetings to which members of the public were invited, the first was held during the annual meeting of the American Public Health Associa- tion in Las Vegas, Nevada, in September 1986. The other meetings were held in Boston, Massachusetts, in October 1986; New Orleans, Louisiana, Febru- ary 1987; and Chicago, Illinois, May 1987. More than 350 people, including citizens of 39 states, the District of Columbia, and Canada, attended these meetings. Attendees included state health commissioners and state health agency officials; local health officers; deans and professors of medical schools, schools of public health, nursing schools, and schools of public administration; federal health officials; consumer representatives; physi- cians, nurses, social workers, health educators, and mental health professionals; representatives of state medical associations, state nurse's associations, and state social worker's associations; directors of public hospi- tals and community health centers; members of state boards of health; and representatives from nonprofit associations. Topics discussed at these meet- ings included the philosophy and scope of public health, specific issues in public health organization, management, leadership and resources, and particular health needs. The committee also held a special meeting on education and training for public health. It was attended by deans and professors from all of the schools of public health, representatives of other educational programs providing public health training, state and local government officials, representatives from national organizations focused on health education, and state and local public health professionals from the field. Presentations were given and discussions held on a variety of issues pertaining to education and practice, including the nature of professional education, the nature of public health as a profession, the relationship between public health practice and education, and the role and activities of schools of public health in educating health professionals. The proceedings of this meeting will be published by the Institute of Medicine in a separate volume. Additionally, the committee collected and reviewed extensive amounts of current and historical literature and data on public health problems and the public health system. Although the committee looked into a broad array of issues in public health, it concentrated on those problems of a public scope rather than health services aimed primarily at the individual. In some cases, this distinc- tion was not easy to make. For instance, most mental health services are directed toward the individual, but all states sponsor mental health pro- grams. Rather than attempt to study both fields, or study such a vast and important topic in an adjunct manner, the committee decided to focus on those aspects of mental health that substantially overlap with public health. During its study, the committee spoke with a number of mental health professionals; discussed several mental health problems that are dealt with

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AN ASSESSMENT OF THE CURRENT PUB LIC HEALTH SYSTEM 77 on a public level, including alcoholism, substance abuse, Alzheimer's dis- ease, and homelessness; and discussed the role of public health in coordinat- ing with mental health programs. But the committee did not make a separate study of the provision of mental health services to individuals, a very large public responsibility in all states. Likewise, the committee's approach to social and human services, many of which intersect with public health concerns, was limited to those having direct interaction with public health activities. The committee paid principal attention to public health at the state and local levels. An extensive amount of information was collected from the federal government, but the federal role in public health was mostly consid- ered as it relates to state and local health systems. THE PUBLIC HEALTH SYSTEM This section describes the public health system as observed by the commit- tee in its research. The discussion focuses on state and local public health agencies-the central agents in the public health system-and their activities and describes other components of the system in relation to health agencies. A brief summary of the organization and scope of the public health system activities at the national, state, and local levels is followed by a description of the ways the system operates in the specific localities visited by the commit- tee in the summer of 1986. Observations on issues and problems of the public health system are drawn primarily from the site visits conducted by the committee, but information presented in meetings and literature and data collected by the committee are also taken into account. SUMMARY OF THE NATIONAL PUBLIC HEALTH SYSTEM State The U.S. Constitution empowers state governments to protect the health and welfare of their citizens through the exercise of police power. States have thus become the central authorities in the nation's public health system. (Grad, 1981) Each of the 54 states and territories of the United States has designated an agency for public health. The organization and leadership of these agencies vary. Some are parts of state superagencies for human services, and some are independent. Some are combined with mental health or environmental agencies, and some are not. (Public Health Foundation, 1986) Some state health agency directors are required to be physicians with public health experience, and some are administrators with management experience. (American Medical Association, 1984)

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78 Trill FUTURE OF PUBLIC HEALTH The state public health agencies carry out each of the public health functions described in Chapter 2: assessment, policy development, and assurance of access to health services. Although general functions are the same, scope of activities and specific activities of health agencies vary tremendously. Some states conduct a wide array of services, and some only a few. Some concentrate on assessment and policy development activities, some concentrate almost solely on assuring access and delivering personal health services. State resources designated to health also vary. (Public Health Foundation, 1986) Finally, state public health agencies differ in their relationships with other state agencies involved in health, in their relationships with local health authorities, and in their relationships with the private sector. Some work closely together, some rarely communicate, and some openly compete. A more detailed description of state health agencies and their leadership, organization, activities, and resources is presented in Appendix A. Local Local health agencies are the critical components of the public health system that directly deliver public health services to citizens. Local govern- ments and local agencies are invested with power by their state governments. (Grad, 1981) Although local authorities may carry out each of the public health functions outlined in Chapter 2, they are generally substantially more involved in assurance activities, largely the actual provision of services to the population. (Miller and Moos, 1981; Public Health Foundation, 1986) Differences in geography and systems of government allow local health agencies to vary even more greatly than state agencies. Some local health agencies are municipal, some serve a county, and some serve groups of counties, or districts. (Miller and Moos, 1981) Some are directed by full-time physician health officers with public health experience; some are run by part- time administrators with little public health experience. (Miller et al., 1977) Some local areas have large, sophisticated health departments that carry out all public health functions with little dependence on the state. Many areas have smaller, more limited health departments that work in conjunction with, or as a branch of, the state health department. And some local areas have no public health department at all. (Public Health Foundation, 1986) Local health agencies also vary considerably in their procurement and allocation of resources. Finally, local health agencies vary in their relationships with other local agencies and with private providers. Some are components of local super- agencies; some are independent. Many rely on private providers to augment services; some have little to do with private providers. Local health agencies and their activities are also summarized in Appen- dix A to this report.

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AN ASSESSMENT OF THE CURRENT PUBLIC HEA ETH SYSTEM 79 Federal The federal government plays a strong role in public health. The federal government conducts public health activities through its power to regulate interstate commerce and its power to tax and spend for the public welfare. (Grad, 1981) The Public Health Service of the Department of Health and Human Services is the main federal authority in health. The federal government is involved in each of the public health functions described in Chapter 2, but its main efforts are in assessment, research, and policy and program develop- ment. Most of its assurance activities are conducted through funding con- tracts with states, local areas, and providers, who actually carry out the service. Some assurance activities are directly carried out by the federal government. (Hanlon and Pickett, 1984) Federal activities in health are described further in Appendix A. Resources In 1984, the nation spent about $387 billion on health care. This figure includes both government and private expenditures for public health pro- grams and personal medical care. Public only, including federal, state, and local government spending, totaled about $160 billion. (Bureau of Data Management and Strategy, Health Care Financing Administration, 1985) Federal spending alone (including Medicare and Medicaid) was about $112 billion or about $460 per person. (U.S. Department of Commerce, 1986) State spending, (excluding Medicaid) totaled about $6 billion, averaging $23 to $26 per person. (Public Health Foundation, 1986; U.S. Department of Commerce, 1986) Local government spending totaled about $2.5 billion. (Public Health Foundation, 1986) In all levels of government, spending on personal health services greatly outweighed spending on population-based public health functions. For ex- ample, the health portion of the budget of the Health and Human Services Department included $95 billion to finance the Medicare and Medicaid programs. The budget for the U.S. Public Health Service, including the Centers for Disease Control; the National Institutes of Health; the Health Resources and Services Administration; and the Alcohol Abuse, Drug Abuse, and Mental Health Administration, totaled only $10 billion. (Execu- tive Office of the President, Office of Management and Budget, 1987) State health agencies spent nearly 75 percent of their funds on personal health services, about $4 billion, while spending less than 1 percent on planning activities, about 3 percent on laboratory analysis and research, and about 9 percent on all resources development. Local health agencies spent, on the average, about 58 percent of their funds on personal health services. (Public Health Foundation, 1986)

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80 THE FUTURE OF PUBLIC HEALTH National and public spending on health care has been a subject of great controversy in the 1980s. Public spending on health care increased dramati- cally throughout the 1960s and 1970s. Much of the federal and state in- creases reflect increases in spending on personal health services and medical care. The Medicare and Medicaid programs were initiated in 1966. While aggregate state health agency spending increased at about 4 percent annu- ally between 1976 and 1984, the proportion of their finances spent on personal health services increased from 48 to 58 percent. (Public Health Foundation, 1987) Spending on assessment and policy activities has not increased so dramatically. In the 1980s, cutbacks in public spending for health care became a national goal. In 1981, federal block grants were initiated which consolidated nu- merous federal health programs into two blocks. These block grants in- cluded a 25 percent cut in funding to states for their programs. (Omenn, 1982) Since 1981, these funds have been partially restored. From 1984 to 1985, the maternal and child health block grant increased 16 percent, while the preventive services block grant increased 21 percent. (Public Health Foundation, 1986, 1987) The GNP growth factor for this period was at 6.8 percent. (U.S. Department of Commerce, 1986) At the same time, state health agency spending increased about 10 percent. (Public Health Founda- tion, 1986, 1987) Nonetheless, these increases are modest compared to increases in some other social programs. During the same period, funding for drug enforcement programs, a particular social goal for this period, increased 550 percent. (Executive Office of the President, Office of Manage- ment and Budget, 1987) Increases in public health spending are not keeping pace with the growing need for assessment, policy development, and assurance activities de- manded by the range of immediate and impending crises and ongoing problems in public health as discussed in Chapter 1, particularly in the assessment and policy development areas. Additionally, resources for par-- ticular needs to fulfill the mission of public health, such as leadership training, are being cut back. Federal funding for health professions training is being phased out, and state resources for leadership training and encour- aging health leaders to take public positions are limited. (Council of State Governments, 1985; Executive Office of the President, Office of Manage- ment and Budget, 1987) Federal, state, and local resources for health are discussed more fully in Appendix A. Other Actors Additionally, it should be noted that other government agencies, such as federal, state, and local agencies in mental health, environmental health, and social services, have an impact on the public health system. And private

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AN ASSESSMENT OF THE CURRENT PUBLIC HEALTH SYSTEM 8] entities, such as health professional organizations, citizen activist groups, health care providers, and voluntary health organizations, also play a crucial role. These other components of the public health system are briefly dis- cussed in Appendix A. THE PUBLIC HEALTH SYSTEM AS OBSERVED BY THE COMMI1-~PE In the six states visited by the committee, six different public health systems were observed. The states varied in their concept of and in the importance they placed on public health. The health agencies in each state varied in organization, authority, activities, and resources. The other actors in the system differed in their participation in public health issues and in their relationships with the health agencies. Nonetheless, many common themes emerged between the sites. The need for more authoritative leadership and greater flexibility in public health was often voiced. Also coveted were organization, consistent services, and the capacity to maintain staff, fi- nances, and information. And particular functions of public health and programs of health agencies were seen as fundamental by many persons interviewed. The following section describes characteristics of the six areas visited by the committee and discusses problems and successes of the health systems in these areas as told by their participants. Organization of Health Agencies Among the six states, two state health agencies were divisions of super- agencies. One state health agency was also the mental health authority; two were also the state Medicaid agency. Five were organized into functional divisions, and one by service populations. The organizational relationships between the state and local health agencies ranged from one in which all local health agencies were largely independent to one in which all local health agencies were run by the state health agency. One state had 114 local health agencies; one had only one. The local health agencies also differed. In one of the states, local health agencies were predominantly municipal; in the rest of the states, they were predominantly or entirely county. Two states had both municipal and county health departments. Two local agencies were large and had numerous divi- sions and hundreds of staff; the rest were small, had only a few programs, and a dozen or two staff at most. In one of the states visited, most of the local areas had no health department at all, but had a private physician who served as a local health officer. Participants of public meetings described other states in which some local areas have no health department. In these areas, there are almost no locally based public health programs.

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82 THE FUTURE OF PUBLIC HEALTH Variation in organization of health agencies existed not only between states but within states. For example, in two cases a superagency existed at one level but not at the other; in several, services that were not combined at one level were combined at the other. For example, in one state the state health agency was part of a superagency combined with social services, but separate from mental health and environmental services. The local health agency visited in this state was independent from the social services agency but had mental health and environmental divisions. Organization of state and local agencies also changed over time. Several of the health departments visited had been organized several different ways throughout their histories. In one state, the state health agency had been completely reorganized a few weeks before the committee's visit. In another state, the section of the health agency dealing with AIDS had recently moved up three levels in the hierarchy and was growing 10-fold in staff and finances. In another, the number of local health agencies had recently been reduced by half, from more than 200 to 114. This had been done mostly by combining small local health agencies. In another state, many pro- grams started by the health department had been relocated to other agencies. The state of flux in health agencies is due partly to the difficulty of segregating health-related functions. For example, there was much sharing of and confusion over environmental responsibilities. The state of flux is also due to the changing circumstances with which health agencies must deal. As new problems such as AIDS and taxies develop, new programs are set up for dealing with them. Or problems become of increased social and political concern, and new programs are developed or existing ones are given in- creased importance. The different patterns of organization in the six states illustrated how the states dealt with the main difficulty in arranging a public health agency, namely, coordinating an extensive array of different types of services that relate to other agencies. One state handled this problem with a health and social services agency and a separate environmental agency. Health pro- grams that addressed needs of a particular population were grouped with social service programs in different divisions of the health and social services agency. Assessment and education activities were dispersed throughout these programs. At the local level, both health and social services agencies existed. In another state, health and social services programs were kept separate, but health and environmental services were combined at both the state and local levels. In a third state, the health agency, the social service agency, and the environmental agency were all separate. Some local health departments were independent, and some were parts of health and social service agencies. Environmental services were handled by multicounty com . . missions.

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AN ASSESSMENT OF THE CURRENT PUBLIC HEA PITH SYSTEM 83 The various arrangements in the states illustrated problems with combin- ing services and problems with separating them. In the state with the superagency, local health officials and some others felt that public health initiatives were lost in the superagency. Some of the state public health officials even expressed a desire to be grouped with the environmental agency, as they felt this would be a more visible location. In a state where the Medicaid program and the health agency were separate, Medicaid policies about financing various health services were set without health agency input. Yet in another state in which the programs were grouped, Medicaid policy seemed to dominate health policy. The committee found that, regardless of organization, health services were often fragmented along organizational lines. In one state, substance abuse programs were handled by the state health agency, but mental health services were the responsibility of the social services agency. Almost no communication took place between the programs. In this same state, the health agency and the environmental agency were also separate, but inspec- tions and data collection activities of both agencies were coordinated at the local level. In another state, local health agencies were responsible for environmental health, but not hazardous waste disposal. When accidents occurred in transport of hazardous waste, health authorities were called at the last moment to inspect the site. In the meantime, they had no knowledge of the potential dangers of the situation. Participants in each of the open meetings described the fragmentation that occurs among social, mental health, and public health services when they are not coordinated. Leadership Five of the states required that the state health officer be a physician; one did not. In five of the states, all of the local health officers were physicians. In one, most were nurses or sanitarians. In many agencies, the health officer directs the agency. But in others, the health officer and the director hold different positions in the agency. In three states and in all but one of the local areas visited, the health officer was the director of the agency. In three states and in one local area the health officer reported to an administrative direc- tor. In two largely rural states, private physicians served part-time as local health officers who worked with the local agency when there was one. The variety of requirements and arrangements for health agency leaders provided examples of strengths and weaknesses in public health leadership. In one state, the health officer was a physician, was director of the state agency, had authority over all local services, and reported to a state board of health. In another state, the health officer, also a physician, filled an advi- sory position and had no line of authority. The administrator of the agency seldom called on this health officer for advice. Local health officers in the first state were physicians, were state employees, and had jurisdiction over

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96 THE FUTURE OF PUBLIC HEALTH pated costs of providing this care directly to the counties, which were by law responsible for medically indigent adults, and directly funded about 100 local primary care clinics, which served primarily minority populations. A fifth state had a catastrophic care fund delegated by the state legislators and by each county. Citizens could apply to their county executive for reimburse- ment of expenses under $20,000, if they could prove need. For expenses above $20,000, state funds became available. The last state was developing a set of basic services to be provided by public or private clinics and financed by the state. The commission designing the program was hoping to provide a package of basic preventive health care services for a cost to the state of $50 per person per month. Several other strategies for state support of indigent care were discussed during open meetings of the committee. Despite all of these various programs, there were many examples of health problems for which services were not being offered by health agencies or by other participants. One state was facing a crisis in obstetrics care. In this state, 14 counties had no obstetric services for poor women. Many physicians were refusing to accept Medicaid patients because they felt that Medicaid rates for this service were insufficient in light of the costs of their malpractice insurance. In one local area, no mental health and substance abuse services were available, notwithstanding a high rate of alcoholism among the popu- lace. Only one private nonprofit clinic offered mental health care in a multicounty area. In another state, health officials mentioned that they had concerns about smoking, but that nothing was being done about this prob- lem. In another, many children were not receiving dental care. Several issues concerning the assurance and delivery of health services were mentioned. In regulation, several participants named areas in which standards were insufficient. Many were trying to increase state regulatory activities for specific programs. In one state, the state agency had recently adopted regulations for certifying water systems operators, in order to enforce more strictly water supply regulations. Another state was hoping to develop regulations on the use of medical devices, in order to limit radiation imposed by these instruments. Another had recently revised its reimburse- ment regulations for subsidizing care for the medically indigent. In many cases, the need for further standards, regulations, and new policies was mentioned. Some states also described difficulties with setting standards and regula- tions in new areas and the risk of meeting with public resistance if the agency is perceived as exceeding its authority. One legislative representative said, "You have to prove there's a real danger before limiting liberty." A citizen of another state said, "We want government out of- as much as possible." A physician at an open meeting commented that too many regulations infringe on private providers. Yet the committee also frequently heard such com

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AN ASSESSMENT OF THE CURRENT PUBLIC HEA PITH SYSTEM 97 meets as "Government ought to be involved in all areas people can't do for themselves, health included." In delivery of personal health services, the most frequently mentioned problem was unmet need. Every state and local area visited had minority or indigent populations that local health and government officials and the citizens felt were being underserved. Participants in open meetings de- scribed problems with unmet need in additional states. A physician at one of the open meetings pointed out that health problems tend to be more exten- sive and more severe in indigent populations. Citizens lacking health care include migrants, illegal immigrants, homeless people, Native Americans, the elderly, people in remote rural areas, and people in inner city ghettos. The need for better and more health services was voiced repeatedly. A Native American representative in one of the states visited said, "It's frus- trating-the health care in Indian Health Service facilities is not anywhere near what's available in the private sector." A health official in another state declared, "We must be clear about the judgment that health care doesn't depend on race, income, or class." Just as frequently, the need for more health education in an entire range of issues was voiced. A health official in a state with a relatively large number of AIDS victims remarked that the agency's entire budget could be spent on AIDS education. Many health officials and providers also mentioned problems with geographic access. The question, said one local health officer in a rural area, is "How much are you willing to pay to have health care within 50 miles?" The extent of unmet need in many areas caused agencies to be concerned about their responsibility to meet all needs, particularly those of indigent populations. In several of the local areas, other resources for personal services were abundant in the form of nonprofit clinics, public hospitals, and private practitioners and the health agency relied on these sources to carry out personal health activities. But in some of the local areas, the health department was one of the few providers of health services, and the agency was having difficulty meeting all needs. Some local agencies mentioned that they have difficulty maintaining preventive, assessment, and environmental services and still provide a large amount of personal services. Other agencies seemed comfortable with both these roles. In a state that provided a majority of the personal health services to its low-income residents, a local health officer said, "We've never questioned providing direct care. Scope may be a problem, but the function is not." Another health official in this state said, "Government has to be responsible for personal health care as well as preventive measures and the environment." But a private provider in a different, but equally economically deprived, state said, "People can't ex- pect the government to provide erection to resurrection coverage." Open meeting participants mentioned that many state governments are unwilling

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98 THE FUTURE OF PUBLIC HEALTH to provide the large amount of funding necessary for providing health care to all indigent people as well as support public health departments. Agencies also mentioned the difficulty of maintaining vigilance on old problems while addressing new issues. In one state, environmental health officials felt that their effort was unduly focused on dangers of radiation from a possible nuclear reactor accident, although the public was suffering more radiation damage from medical devices. A local agency had difficulty calling state attention to an increase in measles cases and the need for greater efforts in measles immunization, because most state officials assumed that measles epidemics are no longer a problem. Many state and local health officials at open meetings described the need for public health agencies to become more involved in health promotion and the difficulty of doing so while maintaining other programs. Intergovernmental and Interorganizational Relationships It is evident in the examples of health agency leadership, assessment, policy-making, and assurance of educational, environmental, and personal health services observed during the site visits that the ability of health agencies to carry out their responsibilities relies in part on their relationships with other participants in the public health system. Many of the activities described above were not and could not be carried out by a local health agency alone. In many cases, the other agencies, private providers, and private associations in the area worked with the public health agency. Relationships in carrying out public health functions are fourfold: between different health agencies at various levels of government, between health agencies and other public agencies, between health agencies and the private sector, and between various private organizations. As in all other aspects of the public health system, the states showed a range of possibilities in all four types of relationships. Relationships ranged from cooperative to competitive to indifferent. In two states, relationships between the state and local agen- cies were minimal. The state health officer in one of these despairingly declared, "The key word here is home rule." The other said, "It's almost heresy to say that the state should involve itself more with locals." In another state, the state and local agencies were a single system. In one state, other public agencies with duties relating to health were well organized and coordi- nated with the state health agency. In another, the agencies did not commu- nicate. In two local areas, many cooperative arrangements existed between private clinics and the health department. In another, private and public clinics maintained a friendly but competitive relationship, and in one local area they virtually ignored one another. The patterns described above were not even consistent to a state or local area. In some places, relationships between public agencies were minimal, but relationships between public and private providers were strong. Or

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AN ASSESSMENT OF THE CURRENT PUB f IC HEA FTH SYSTEM 99 relationships between organizations would be strong on a particular health issue, but not on other issues. In two of the states, although relationships between the state health agency and local agencies were minimal, consider- able networking between state-level agencies took place in one state, and networking between the local agencies and private providers took place in both. In one of these states, environmental agencies collaborated on issues with the state health department, but the mental health agency did not. And the local area had extensive networks for maternal and child health and AIDS, but not for mental health and health care for the homeless. Numerous examples of successful coordination between public agencies and between public and private agencies were described to the committee. Several local health agencies mentioned that they were receiving assistance from the Centers for Disease Control or special funds from another federal agency. In one state, a board of environmentally related agencies, including health, had been formed to investigate the nuclear waste issue. In one local area, the health agencies of nine counties had joined together and joined with the community clinics in the area to form a consortium for primary health care. The organizer of this consortium was the local health officer for two of the counties. In another local area, the health department had set up a system that included health department clinics and private hospitals for delivering prenatal and obstetrics care to indigent women. In one state, private professional associations and the state legislature and citizen groups had banded together to promote a smoking cessation campaign. But many interviewees also described situations in which they felt greater coordination would be desirable. In the two states in which the Indian Health Service had facilities, almost no contact was taking place between the federal service and the state agencies. In one of these states, the Indian Health Service, the state health agency, and the state mental health agency were arguing about responsibility for adult and aging services. In another state, numerous environmental agencies existed, all dealing with different envi- ronmental issues, and none of them dealing with the health agency. In another local area, most health issues were handled without contact between the health department, the public hospital, and various nonprofit clinics in the area. Problems associated with communication in the public health system were described. Some agencies felt that relationships between health agencies at different levels of government were more formal than functional. Some health officials even described their relationships as dictatorial. A represen- tative anecdote concerns the state health officer who instituted new regula- tions defining local health departments without consulting local health de- partments. Problems were also mentioned with interagency communication. Several agencies were accused of "turf-guarding." Officials bemoaned the lack of

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100 THE FUTURE OF PUBLIC HEALTH definition among responsibilities, particularly between environmental and public health programs. In one area, the local health officer felt that none of the numerous state environmental agencies took responsibility for local environmental issues, so these problems had been left to the local health department. In one state, the state health agency felt hampered in its efforts to enforce rules on individual water supply, because responsibilities were split with the state environmental agency. Officials also described overlap problems with personal health programs. In one state, the Medicaid agency and the state health department were described as collecting the same information from providers without sharing data. In the states with signifi- cant Native American populations, Indian Health Service programs were run completely independently from those of the state. This practice caused difficulties for Native Americans living outside of reservations, and for people who are only partially Native American, who are sometimes denied service by both state and federal programs. Some problems were also described in health agency communication with the private sector. Many agencies said that cooperation between the public and private sector was imperative. Said a state health agency director, "We have to maintain good relationships with the private doctors; if they won't work with us, we're dead in the water." But some meeting participants said that if the health department relies too heavily on private providers, it can lose control of programs. Others described competition between public and private providers. Said a state official, "We have a statewide system of home health care we get a lot of competition from private providers." In this state, the state agency considered competition helpful, but the director of one private home health agency did not. A private physician in one area of the state said, "If the health department routinely refers patients to [another area], they keep on going, and we lose patients." In this same state, the committee heard that a local health agency was not accepting referrals from the local community health center. Participants in the open meetings pointed out that many physicians are unwilling to become involved with the health department because fees for services are so low or funding for pro- grams is cut without warning. Resources The six states visited illustrated patterns of financing and difficulties with constrained resources indicated by national trends. The six states varied in their basic economic situations; in the amount of money their health agencies received from federal, state, and local sources and how these finances were allocated; in the manner in which finances were shared between state and local agencies; in the amount spent on different types of programs; and in their staffing of state and local agencies. Two of the states visited were among the wealthier in the nation. One was

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AN ASSESSMENT OF THE CURRENT PUBLIC HEALTH SYSTEM ]0] recovering from a recession in the early 1980s, in which large numbers of residents had lost their jobs. Another was beginning to feel severe effects from the current national farm crisis. And two were among the most chron- ically poor in the nation. The local areas visited followed much the same patterns as their states, although two of the local areas in the wealthier states were substantially less economically well-off than the state average. And one local area was generally better off than the majority of areas in the state. State per capita health expenditures ranged from $72 to $172 among the six states in 1984. (U.S. Department of Commerce, 1986) Also in 1984, total state and local health agency expenditures ranged from $736 million in the largest, most populated state to $14 million in the least populated state. These figures were $517 million and $13 million for the same states in 1980. (Association of State and Territorial Health Officials, National Public Health Program Reporting System, 1981; Public Health Foundation, 1986) In 1984, total state and local health agency funding derived from federal contracts and grants ranged from 10 to 60 percent in the six states. Funds from the states ranged from O to 60 percent. Local funds accounted for O to 60 percent. (Public Health Foundation, 1986; see Figure 4.1) The percentage of federal funds allocated for general administration "core" support in the states ranged from O to 2 percent. loo 50 _ State \ \ in. Local ~ , ,~, State ~ l ~: L ~ Local A B C ~ l i, i, Local ad, State ~ Federal Grants and Contracts [~ State Funds ~3 Local Funds - : : ~, ',.,, State Pid:\1 Local State Local State Local D E F Fees and Reimbursements Other FIGURE 4.1 State and local agency sources of funding for six states, 1984. SOURCE: Public Health Foundation, 1986.

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102 THE FUTURE OF PUBLIC HEALTH Program expenditures of state and local agencies for different health programs varied throughout the states (see Figure 4.2~. For example, agen- cies spent as much as 95 percent to as little as 45 percent of their budgets on personal health services. Within this, funding for specific services varied. For example, in two of the states that were similar in population size and economy, one of the state agencies spent $1.6 million on health statistics activities, while the other spent $500,000. In communicable disease control, one spent nearly $8 million and the other spent $860,000. In maternal and child health services, one spent $52 million and the other spent $20 million. (Public Health Foundation, 1986) Finances from health agencies were not the only source of funding for health programs. Individuals in states and localities frequently mentioned finances from other sources. Sometimes special programs had been ar- ranged with additional grants from federal sources. Sometimes funding had been received from private foundations. For example, one local area had a community-based program for AIDS victims financed by The Robert Wood Johnson Foundation. In one state, the Appalachian Regional Commission had assisted with many programs. In all of the states, health care providers as well as agencies mentioned Medicaid, Medicare, and Social Security as 100 IL () So IIJ iii a,`\ %` ~ ''my State \\ Local a_ Personal Health Environmental Health Health Resources l ~ ~ l ~ ~1~! State Local State 7J I 7 J J ~-`'v Local State J T r I T I ,~,. <~ ,% ,~ ,i,t,,-~ ,`_- ~,_~; :".' _ Local 1 a my' <,%~ State Local 7 7 1 ~ i, : ~ ~f4 l l . 1 1 1 1 ~ 1 (~ State Local B C D E F Laboratory General Administration Not Allocated N/A Not Available FIGURE 4.2 Areas of expenditure of state and local health agencies in six states, 1984. SOURCE: Public Health Foundation, 1986.

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AN ASSESSMENT OF THE CURRENT PUBLIC HEALTH SYSTEM ]03 sources of finances. And public health spending also took place in environ- mental, mental health, social service, and agricultural state agencies. In staffing, the state agencies ranged in number from 312 full-time em- ployees to more than 4,000. In four of the states, the number of agency staff was remaining fairly constant. One state was planning a large increase in staff in one particular program. Another had lost a small number of staff. The number and type of professional staff varied between agencies. One state agency had only one physician in the agency, the health officer, who filled an advisory role to the director. Another health agency had a physician with a master's degree in public health heading nearly every program. One of the states had physicians from the U.S. Public Health Service working in the agency. One local area had a physician from the National Health Service Corps. Most of the state agencies had a large number of nurses on staff; in one of the agencies, nurses made up nearly a quarter of the staff. Each of the states had only a few health educators. Planners, data analysts, and statisti- cians generally made up less than 10 percent of the staff in all of the six state agencies. In three of the states, environmental personnel made up about 10 to 20 percent of the staff. (Association of State and Territorial Health Officials Foundation, 1985) Staff of the local agencies ranged from a few dozen to more than 600. The smallest had no physicians on staff; the largest had several. All of the agencies had several nurses on staff; a few had health educators; most had sanitarians. All had at least one administrative staff person. Only the larger agencies had separate staff for vital statistics activities. The number of staff was fairly constant in most localities. In most of the areas, the populace relied on private health care profession- als to provide services as well as on health agency staff. The number of public health professionals and health care professionals in the states and localities working outside of the public health agencies varied; physicians per 1,000 population ranged from 107 to 230 in the six states. (U.S. Department of Commerce, 1986) Two of the states had public health schools within the state. Each state had at least one medical school. And each had at least one nursing school. In the local areas, the numbers of private physicians ranged from three or four to a county in the most rural sites to hundreds in the large cities. Nurses ranged from only a few to several hundred. And hospitals and clinics ranged from dozens to only one or two to a county. Several states were engaged in special activities in resources development. One had a governor's conference on wellness. Another had raised special federal funds for high-risk maternity care, and the agency in this state was also encouraging physicians to accept jobs in underserved areas and training pediatricians and nurses in high-risk maternal care. One state agency had obtained funding from a private organization to start up an insurance pro

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104 THE FUTURE OF PUBLIC HEALTH gram for small employers. And another was seeking funding for research on the numbers of and health needs of illegal immigrants to the state. One state had a special program for training and hiring physicians specializing in preventive medicine. The most frequent problem mentioned concerning resources in site visits was the lack of funds to support ongoing and new health programs. This problem was reiterated throughout open meetings. Although state and local agency people in the sites did not complain a great deal about past budget cuts, a general lack of finances was frequently mentioned. Many felt that departments could not adequately fulfill all of their responsibilities because of lack of funding. A state health official said, "You know you'll get blamed if things go wrong, but no one will give you the money to help you get ready." And a county supervisor described their dilemma, "We rob Peter to pay Paul just to put out the fires." Several health officials mentioned programs or activities that were in danger of being cut because of lack of funding. A local health officer told the committee, "The county hospital pays for ambulance service, but it's losing money-we can operate the service through next year, but after that.... " A clinic director in the same local area, a rural county with a large migrant population, said, "Refugee money will be ending this year-I don't know how we'll continue to provide services." Public health officials also described limiting programs because of financial ability. A state health official said, "First you define a problem, and then you decide if you can afford it." A local health official in an area with high infant mortality rates told the committee, "The high-risk pregnancy program is limited in number due to funds." And a public health agency clinic administrator confided, "We constantly prescribe less expensive medications or put off tests." Many health officials and providers mentioned concern about in- creasing indigent care and uncompensated care in their states. Some officials feared further cutbacks. A state health officer declared, "If revenue sharing goes down, 22 local health departments will have to close." One of these local health departments said it had no alternative but to shut down if federal funds were lost. Several other departments mentioned the need to seek funding for programs from other sources. One state health officer said, "In a poor state we have to look at wherever we can find the funds we can't sit back and decide this is impossible, now bring us the money for it." Some also mentioned a lack of staff. In one local agency, the local health officer felt that his abilities had been severely limited by loss of a key colleague. Participants in open meetings also mentioned problems with staff shortages. A few site visit residents mentioned concerns about training public health personnel. They mentioned that training should include political and com- munication skills, as well as scientific and technical skills. One state health officer said, "Public health training is narrow and disciplinary, not outcome oriented. We say we're scientists, not politicians." A public health professor

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AN ASSESSMENT OF THE CURRENT PUBLIC HEALTH SYSTEM ]05 said, "We need to teach people to say 'ten leading cripplers and killers,' not morbidity and mortality." The difficulties of providing education that both trains frontline workers and educates leaders was extensively discussed at one of the committee's meetings. The need to interest medical school students in public health and preventive medicine was mentioned at another open meeting. The committee also noticed that the training and background of officials in state and local health departments visited varied tremendously. In some agencies, most officials had training in medicine, public health, nursing, health education, or a related field. But in some agencies, few had public health-related training. Many had spent long careers in public health, but some had no public health experience prior to employment in the agency. CONCLUSION The above description of the public health system is meant to highlight its diversity and its dynamism. The system is a problem-processing activity, involving many participants in different settings and in different disciplines, who deal with similar and with individual problems. The variety throughout the system is a consequence of the different values and participants present in each area and of how these participants determine problems, make decisions about needs, and organize and allocate resources to meet needs. Autonomy and the right to make independent relevant decisions about needs in local areas is a fundamental American approach to government. But there are also values, equally fundamental, that support the need for government to provide or make available core public health functions and activities to all citizens. These values and issues were discussed in Chapter 2 of this report. Observation of the current public health system, as described in Chapter 4, shows that some states and some local areas are more able to fulfill these functions than others. Some far exceed the minimum, but some don't meet it. The following chapter evaluates the current system as de- scribed and considers problems and opportunities for bringing the current system, as a whole, closer to the ideals expressed in Chapter 2. REFERENCES American Medical Association, Department of State Legislation, Division of Legislative Activ- ities. 1984. State Health Departments. American Medical Association, Chicago, Ill. Association of State and Territorial Health Officials Foundation. 1985. Staffs of State Health Agencies. ASTHO 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 Their Expenditures and Activities. ASTHO, Washington, D.C.

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06 THE FUTURE OF PUBLIC HEALTH Bureau of Data Management and Strategy, Health Care Financing Administration. 1985. HCFA Statistics. U.S. Department of Health and Human Services, Washington, D.C. Council of State Governments. 1985. The Book ofthe States, 1984-5. Council of State Govern- ments, Lexington, Ky. Council of State Governments. 1987. The Book ofthe States, 1986-7. Council of State Govern- ments, Lexington, Ky. 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. 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 Mirrort Mosby. Miller, C. Arden, and Mary K. Moos. 1981. Local Health Departments: Fifteen Case Studies. American Public Health Association, Washington, D.C. Miller, C. Arden, 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):931-39. Omenn, G. S. 1982. "What's Behind Those Block Grants in Health. " New England Journal of Medicine 306(17):1057-60. Public Health Foundation. 1986. Public Health Agencies, 1984, vole. 1, 2, and 4. Public Health Foundation, Washington, D.C. Public Health Foundation. 1987. Public Health Agencies, 1987. Public Health 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.