Public Health System: Structure and function CHAPTER OUTLINE ADMINISTRATION OF U.S ADMINISTRATION OF U. S PUBLIC HEALTH 309 PUBLIC HEALTH A. Responsibilities of the Federal G Commerce 309 A. Responsibilities of the Federal Government 2. Taxation for the General Welfare 309 3. Provision of Care for Special Groups 310 The public health responsibility of the U.S. Federal Govern 4. Funding Federal Legislation 310 ment is based on two clauses from article 1, section 8 of the 5. Coordination of Federal Agencies 3I0 U.S. Constitution. First, the Interstate Commerce Clause B. Responsibilities of States 312 gives the federal government the right" to regulate Com- C. Responsibilities of Municipalities and Counties 33 merce with foreign Nations, and among the several States and with the Indian Tribes Second, the general welfare Basic six " to 10 essential services 314 Clause states that the Congress shall have Power to lay and 2. Health Director's Duties 314 collect Taxes.. for the common Defense and general Welfare 3. Environmental Protection 315 of the United States, Federal responsibility also is inferred II, BROADER DEFINITIONS OF PUBLIC HEALTH POLICY 315 from statements that Congress has the authority to creat and support a military and the authority to negotiate with Ill. INTERSECTORAL APPROACH TO PUBLIC HEALTH 315 Indian tribes and other special groups IV, ORGANIZATIONS IN PREVENTIVE MEDICINE 316 V. ASSESSMENT AND FUTURE TRENDS 316 . Regulation of Commerce VI. SUMMARY 316 The regulation of commerce involves controlling the entry REVIEW QUESTIONS, ANSWERS, AND EXPLANATIONS of people and products into the United States and regulating commercial relationships among the states. People may be excluded from entry to the United States if they have infec- tious health problems, such as active tuberculosis. Products The U.S. Institute of Medicine(IOM)describes the chal- may also be excluded from entry, such as fruits and vegeta- lenges inherent in organizing the public health system for bles if infested with certain organisms (e. g, Mediterranean the 2lst century as follows fruit fly) or treated with prohibited insecticides or fungi cides In the past, similar prohibitions have been extended to The systems and entities that protect and promote the publics the importation of animal products from cattle that might health, already challenged by problems like obesity, toxic envi- contain the prions of bovine spongiform ronments, a large uninsured population, and health disparities, and, as recently in 2011, produce that might be contami- must also confront emerging threats, such as antimicrobial nated with Escherichia coli resistance and bioterrorism. The social, cultural, and global cor The regulation of commercial relationships between texts of the nations health are also undergoing rapid and dra- states has increased over time. Contaminated food products matic change. Scientific and technological advances, such as hat cross state lines are considered to be "interstate com- genomics and informatics, extend the limits of knowledge and merce"; what crosses state lines are harmful microorganisn human potential more rapidly than their implications can be The federal government takes the responsibility for inspect- absorbed and acted upon. At the same time, people, products ing all milk, meat, and other food products at their site of d germs migrate and the nations demographics are shifting production and processing.(In contrast, the state or local in ways that challenge public and private resources government is responsible for inspecting restaurants and food stores. Likewise, polluted air and water flowing from The U.S. public health system was designed at a time state to state are deemed to be "interstate commerce"in pol when most threats to health were infectious, before com lution and come under federal regulation puter information systems, and when local autonomy pi vailed. This chapter describes the structure of the U.S. health 2. Taxation for the General Welfare challenges. Public health systems in other countries are likely The power to "tax for the general welfare"is the constitu- structured very differently but still need to adapt to the same tional basis for the federal government,'s development of challenges most of its public health programs and agencies, including 309
SECTION 4 Public Health the Centers for Disease Control and Prevention(part Social Security Act. Medicare is covered under Title 18 of Department of Health and Human Services)and the the Social Security Act and pays for medical care for the pational Safety and Health Administration(OSHA, lderly population. Medicaid is covered under Title 19 and the Department of Labor); for research programs, such as pays for medical and nursing home care in cooperation with those of the National Institutes of Health(NIH); and for the the states(see Chapter 29). CMS duties include setting stan- payment for medical care, such as Medicare and Medicaid dards for programs and institutions that provide medical (see Chapter 29) care, developing payment policies, contracting for third party payers to cover the bills, and monitoring the quality of 3. Provision of Care for Special Groups care provided. CMS also supports graduate medical educa- tion, residency, and fellowship programs that provide care The federal government has taken special responsibility for individuals covered by Medicare or Medicaid for providing health services to active military personnel, through military hospitals; families of military personnel, through military hospitals or the Civilian Health and Medical PUBLIC HEALTH SERVICE Program of the Uniformed Services; veterans, through the The U.S. Public Health Service(PHS) comprises the follow Veterans Administration hospital system; and Native Ameri ans and Alaska Natives, through the Indian Health Service of the u.s. public health service he Agency for Healthcare Research and Quality (AHRQ) is the main federal agency for research and 4. Funding Federal Legislation policy development in the areas of medical care organiza- tion,financing, and quality assessment. Since 2000, the Funding of federal legislation requires a two-step process The initial bill provides an authorization of funds. An authorization bill only sets an upper limit to the amount of 2. The Agency for Toxic Substances and Disease Registry funds that can be spent No monies can be spent, however ATSDR) provides leadership and direction to programs until they have been specifically appropriated for that bill designed to protect workers and the public from exposure purposes in a subsequent appropriations bill. The authoriza to and adverse health effects of hazardous substances that tion is a political fiction for which members of Congress can are kept in storage sites or are released by fire, explosion, or accident tends to be about half the amounts authorized in the bills, 3. The Centers for Disease Control and Prevention(CDC) and the amounts are usually appropriated for only one fiscal has the responsibility for"protecting the public health of ear at a time. It is in the funding bills that fiscal(and politi the[United States] by providing leadership and direction al)reality must be faced. Because a funding bill covers many in the prevention and control of diseases and other pre ems,the voters usually are unaware that the amount actu ventable conditions and responding to public health ally appropriated is much smaller than the amount promised emergencies. The CDC directs and enforces federal quar- he authorization bill antine activities: works with states on disease surveillance and control activities; develops programs for prevention 5. Coordination of Federal Agenci and immunization; is involved in research and training; makes recommendations on how to promote occupa In the United States the federal department most concerned tional health and safety through the National Institute with health is the Department of Health and Human Ser on Occupational Safety and Health(NIOSH); provides consultation to other nations in the control of prevent described next(Fig. 25-1) able diseases; and participates with international agencies the eradication and control of diseases around the ADMINISTRATION ON AGING world. The CDC has a complex organizational structure The Administration on Aging provides advice to the Secre- 4. Th825-2) ood and Drug Administration(FDA)is the primary tary of the dhHS on issues and policies regarding elderly gency for regulating the safety and effectiveness of drug persons. It also administers certain grant programs for the for use in humans and animals vaccines and other bio benefit of the aging population products including ionizing and nonionizing radiation-emitting ADMINISTRATION FOR CHILDREN AND FAMILIES electronic products. The FDA is also responsible for the fety, quality, and labeling of cosmetics, foods, and food The Administration for Children and Families is additives and colorings for administering child welfare programs through the stat 5. The Health Resources and Services Administration Head Start programs, child abuse prevention and treatment (HRSA)is responsible for developing human resources programs, foster care, adoption assistance, developmental and methods to improve health care access, equity, and disabilities programs, and child support enforceme uality, with an emphasis on promoting primary care HRSA also supports training grants and training pro- CENTERS FOR MEDICARE AND MEDICAID SERVICES grams in preventive medicine and public health. 6. The Indian Health Service promotes the health of and The Centers for Medicare and Medicaid Services(CMS)is rovides medical care for Native Americans and Alaska esponsible for administering two major programs of the Natives
CH ER 25 Public Health System: Structure and Function The Executive Secretariat Secretary Deputy Secretary Office Office of Health Reform and Extemal Affairs (EA (OHR) Chief of staff Office on Disability Strategic Information (osSI Administration for Children Centers for medicare d Neighborhood (ASA) (ACF) (CFBNP) Program Support Office for Civil Rights Administration on Agin Food and Drug (FDA) fice of the Assistant Secretary for Financial ASFR gency for Healthcare Research and Quality Services Administration AHR (HRSA Office of the assistant Secretary for Health Office of the general nd Disease Registry ind an Health Office of the assistant ecretary for Legislation Office of Global Affairs Centers for Disease Control National Institutes of health* (OGA) and Prevention Secretary for Planning (ASPE) Health Services Office of the Assistant SAMHSA Preparedness and gs and Appeals (ASPR OMHA Office of the Assistant heesigpates a emp sent ce Secretary for Public (ASPA) Information Technology Figure25-iu.s.dEpartmentofhEalthandHumanServices(dhhs)organizatIonalchart.(fromhttp://www.hhs.gov/about/orgchart.) 7. The National Institutes of Health(NIH) consists of 2 8. The Substance Abuse and mental health institutes, which perform intramural (in-house)research Administration(SAMHSA) provides national l on their particular diseases, organ systems, or topics(e.g in preventing and treating addiction and othe National Cancer Institute; National Heart, Lung, and disorders based d Blood Institute: National human genome research insti has four major operating divisions: Center for Mental tute: National Center for Advancing Translational Health Services, Center for Substance Abuse Prevention Science). The institutes also review and sponsor extramu Center for Substance Abuse Treatment, and Center for ral research at universities and research organizations Behavioral Health Statistics and Quality. through competitive grant programs. Some of the inst tutes also undertake disease control programs and public The PHS is not the only important agency in public and professional education in their area(e.g, National health. The other major federal organization is the Office of Library of Medicine, National Institute for Neurological Public Health and Science(OPHS), which leads the Healthy People initiative through its Office of Disease Prevention and
312 SECTION 4 Public Health Office of the Chief of Stafl caT Office of the Office of Diversity Management Director Office of the Assoc ate D recor Office of Minority Health and Office of the Assoc ate direc ce of Public Health Office for State, Tribal, Lccal and redness and ResponsecG Ofice of Surveillance, Epidemiology and Laboratory Services in u oy and emyrmnicanta hsa abes. Office of Infectious Diseases National Institute for National Center for Heath National Center on Birth Statistics Center for Global Heal Safety and Health NDiseas e preer otion hon ractce Program Office and Zoonotic Infectious Iseases cVL Technology Program Office Environmental Health/A ral Hepatitis, STD and TB Toxic Substances and Public Health Surveillance Professional Develoment Approved 7/27/20 Figure 25-2 u.S. Centers for Disease Control and Prevention( CDC)organizational chart. STD, Sexually transmitted disease; TB, tuberculos (frOmhttp://www.cdc.gov/maso/pdf/cdc-offcial.pdf) Promotion(see Chapter 26)and oversees the U.S. Surgeon 2. The policy development role requires that"every public General's office President's Council on bioethics U.S. Public health agency exercise its responsibility to serve the Health Service Commissioned Corps, and Office of Minority lbic interest in the development of comprehensive Health(Fig. 25-3) public health policies by promoting the use of the scien tific knowledge base in decision-making about public developing public health policy, B. Responsibilities of States nd by taking a strategic approach, developed on the basis f a positive appreciation for the democratic political In the United States the fundamental responsibility for the process health of the public lies with the states. This authority derives 3. The assurance role requires that"public health agencies from the 10th Amendment to the Constitution: The powers assure their constituents that services necessary to achieve not delegated to the United States by the Constitution, nor agreed upon goals are provided, either by encouraging prohibited by it to the States, are reserved to the States action by other entities(private or public sector), by respectively, or to the people quiring such action through regulation, or by providing In 1988 the IOM stated that"the mission of public health services directly. 3 to ensure conditions in which people can be healthy",and that the three core functions of public health agencies at all within these three core functions, 10 essential public levels of government are assessment, policy development, health services have been defined(Box 25-1). Administrators and assurance and others involved in public health have been struggling to define how the mission and three core functions can best be 1. The assessment role requires that" every public health fulfilled. As indicated by the assurance role, public health agency regularly and systematically collect, assemble, agencies enjoy considerable latitude. Although not required analyze, and make available information on the health of to provide all (or even most of)the services themselves, the the community, including statistics on health status, com- agencies are expected to use all their authority and resources munity health needs, and epidemiologic and other studies to ensure that needed policies, laws, regulations, and services of health problems eXIs
CH ER 25 Public Health System: Structure and Function Office of Public Health and Science(OPHS) USPHS Office of disease Administrators Corps Office Division 兰 Medical HIVAIDS Office of Office of Office Physical Fitness Figure 25-3 u.S. Offce of Public Health and Science(OPHS)organizational structure. HIV/AIDS, Human immunodeficiency virus and acquired Each state has a health department to perform or overse the performance of the 10 essential public health services Governmental Public Health The state health department oversees the implementation of Infrastructure: The I0 Essential Publi the public health code, a compilation of the state laws and Ith Services regarding public health and safe ules passed by a legislature. In contrast, regulations are technical rules added later by an empowered body with spe- 1. Monitor health status to identify community health cific expertise, such as a state or local board of health. In some states, responsibility for mental health services falls to 2. Diagnose and investigate health problems and health the health department, whereas other states have separate departments of mental health services. Every state also licenses medical and other health-related practitioners and Public Development medical care institutions, such as hospitals, nursing homes 3. Inform, educate, and empower people about health issues. nd home care programs. 4. Mobilize community partnerships to identify and solve health problems ans t C. Responsibilities of Municipalities ommunity health efforts and counties Assurance 6. Enforce laws and regulations that protect health and ensure Although the states hold the fundamental police power to protect health, they delegate much of this authority to cha 7. Link people to needed personal health services, and assure tered municipalities, such as cities, or other incorporated the provision of health care when otherwise unavailable. areas. These municipalities accept public health responsibili- 8. Ensure a competent public health and personal health care ties in return for a considerable degree of independence from the state in running their affairs, including property 9. Evaluate effectiveness, accessibility, and quality of personal ownership and tax levies. In this respect, they differ from and population-based health services counties(called parishes"in Louisiana). Counties Serving All Functions bureaucratic subdivisions of the state created to administer 10. Research for new insights, and innovate solutions to ilities(with rying degrees of local cor health problems uch as health services, as well as courts of law, educational programs, highway construction and maintenance, and Modified from Public Health Functions Steering Committee, 1994; police and fire protection American Public health Association. Association of Schools of the Local public health departments usually are administra Public Health Association of State and Territorial Health Officials, tive divisions of municipalities or counties, and their policies Environmental Council of the States, National Association of are established by a city or county board of health. These County and City Health Officials, National Association of State boards of health have the right to establish public health laws Alcohol and Drug Abuse Directors, National Association of State and regulations, provided that they are at least as strict as ental Health Program Directors, Public Health Foundation, US similar laws and regulations in the state public health code, Public Health Service. and provided that they are reasonable. Anything that is too