the fact that the Constitution leaves untouched the states’ sovereign power (sometimes called “police powers,” discussed below) over most health issues and limits the role of the federal government primarily to (1) regulation of foreign and interstate commerce issues—and by extension, health issues and threats that could affect commerce, and (2) the power to tax and spend for the public welfare (Gostin, 2010; Grad, 2005).

The organization of public health at the federal level consists of the Department of Health and Human Services (HHS), which includes the Centers for Disease Control and Prevention (CDC) that function as the nation’s lead public health agency, the Food and Drug Administration (FDA), and several other pertinent agencies each of which has multiple functions relevant to health. Other federal departments and agencies have health-related duties. These include the Department of Agriculture, whose functions include setting dietary guidelines, ensuring food safety, and administering the national program that sets and enforces organic standards; the Environmental Protection Agency, which is charged with protecting Americans from risks to health and to their environment; and the Occupational Health and Safety Administration, in the Department of Labor, which is given oversight of workplace safety and health issues. The federal public health agencies were created by administrative statute, and their actions are authorized by the Public Health Service Act first passed by Congress in 1944 and by a host of other laws (Goodman et al., 2006).

Below the federal level, the organization of public health is similarly complex, and the existing classification system for how public health is structured has had numerous iterations over several decades (see for example the earliest descriptions in DeFriese et al., 1981 and Miller et al., 1977). Each structural arrangement may have advantages and disadvantages in terms of the agencies’ ability to function and shape public policy, cultivate legislative champions, and secure needed funding, but given the heterogeneity among agencies and locales, there is little research on the topic and very limited resources to support it. First, there are four primary organizational models for state public health agencies, depending on whether the public health component is stand-alone or combined with other functions, such as mental health, substance abuse and human services programs, although this typology is often abridged to stand-alone agencies and umbrella agencies (ASTHO, 2007) (see Box 2-1). The statutes or laws that authorize state public health agencies are grounded in the US Constitution which both constrains their actions and allows them significant powers. Second, three models describe the administrative relationship between state and local public health organizations (or how states deliver services). These include a decentralized or home rule arrangement, under which local public health agencies operate independently of the state and report to local government; a centralized model in which there are no local public health agencies,



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