• new challenges and opportunities to maintain and improve quality of life,

  • variable and diverse governmental tools and structures (Walker, 2003), and

  • the many serious and long-standing threats to health that may be resolved, in part, only through additional research.

Second, globalization—the growing interdependence among enterprises, economies, and governments—complicates any effort to improve or protect health, placing many risk factors beyond the department’s control. For example, the globalization of the food supply has the potential to introduce a wide range of contaminants. Organisms that produce infectious diseases can now move rapidly through air travel and the movement of people across countries. Changing demographics, including high levels of immigration into the United States from every continent, introduce a greater range of health behavior and present cultural differences that create communication and health education challenges.

Third, the burdens imposed by disease and disability do not lend themselves to the equal or “fair” distribution of government protections that citizens influenced by almost a half century of advances in civil rights and consumer advocacy now expect. Some diseases of great severity, prevalence, and emotional cost have as yet no known treatment, so their victims suffer disproportionately. Some populations are at greater risk of certain diseases or complications, so they too suffer more than others. Children, the mentally ill and developmentally disabled, and other vulnerable groups cannot readily advocate for better health care for themselves. And, access to care is not uniformly available nationwide, since health professionals generally gravitate to larger, more prosperous communities, leaving many rural and low-income communities underserved.

Fourth and finally, HHS has an extraordinarily broad reach throughout the U.S. health care system and many types of relationships:

  • Through its payment programs, HHS exerts regulatory influence over virtually all acute care hospitals, most physician practices, and many other health care providers. It affects more than 80 million Medicare and Medicaid beneficiaries (U.S. Census Bureau, 2008) and influences the flow of health information they receive.



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