health care usa chapter 11

7/24/2019 Health Care USA Chapter 11

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Chapter 11

Public Health and the Role

of Government in HealthCare


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CHAPTER OBJECTIE!

Defne and characterize public healths coreunctions, responsibilities o the public healthsector and public health code o ethics

Understand the history and evolution ogovernments roles in health care andrelationships with private medicine

Review challenges in implementing a

population ocus in U.S. health care deliverysystem

Review maor provisions o the !"! a#ectingpublic health


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Public Health "e#ned $1%

$%#orts made by communities to copewith health problems arising rompeople living in groups&the need to

control transmission o disease,maintain a sanitary environment,provide sae water and ood, and

sustain people with disabilities andlow income populations.'


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Public Health "e#ned $&%

(ublic health concepts re)ect*

"urrent +nowledge o the nature andcauses o diseases

(ractices o disease control and treatmentDominant social ideologies o communities

rounded in social ustice, applies medicine,epidemiology, statistics, social, behavioral,environmental, other disciplines


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Public Health "e#ned'Ecolo(ical )odel*

-ncorporate numerous$determinants' that impact healthstatus o groups, e.g. physical

environments, political conditions,human biology, socioeconomicactors, behavioral choices, cultural

norms %/plain $healthy state' or its

absence0 acilitate development o

e#ective interventions


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Earl+ Ori(in* of PublicHealth $1%

1ebrews* spiritual cleanliness andcommunity responsibilities

ree+s* personal hygiene to achieve

mind2body balance Romans* water systems, sewage

disposal 3 swamp drainage0

infrmaries or sic+, poor were frst$public hospitals'


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Earl+ Ori(in* of Public Health$&%

4edieval (eriod 5verpopulated,flthy walled towns spawnedepidemics, superstitious, demonic

and theological theories o diseasedisplaced earlier attention topersonal hygiene and sanitaryenvironment.

Renaissance (eriod rebirth o art,literature and science0 productionand world trade demanded healthy

laborers and soldiers0 centralized


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Public Health in En(land

(overty, illness, disability common0support or medical care in privatehomes, public infrmaries

%lizabethan (oor 6aws o 7897*government provisions or the $lame,impotent, old, blind, and such other

among them being poor and unableto wor+.'


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7:thcentury* frst collection, analysis onational data on industrial production,demographics0 population 3 disease

specifc mortality rates lin+ed socialactors with health and disease ;

7?th

century* =ohn @ellers e/hortednational responsibility or hospitals, labsand medical care0 population healthshould be a national concern.


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(oor 6aw !mendment !ct o 7?AB*reduce public dependency, spurproductivity0 aid only to ablebodied in

e/change or labor in wor+houses (oor 6aw "ommission* lin+ed health

conditions to the economy0 data lin+edpopulation characteristics,

environmental conditions with diseaseincidence

!ter years o debate, 7?B? (ublic

1ealth !ct passed creating eneral@oard o 1ealth a model national


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"evelopment of ,-!- Public Health .Government/!upported !ervice* $1%

"olonial periodC7?99s* Strongin)uences o the @ritish model* E(oor 6aw ;7:??> established

almshouses %pidemics stimulated sanitary

reorms

!lmshouses and townemployedphysicians dominated till the 7FA9s.


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"evelopment of ,-!- Public Health .Government/!upported !ervice* $&%

7?G9* 6emuel Shattuc+, statistician*conducted U.S. sanitary surveys omorbidity, mortality rates related to

environmental conditions0 advocatedcity, state responsibility Sanitary "ommission Report* Hirst ignored,

now most in)uential document in evolution oU.S. public health0 emulated "hadwic+

7?8G* E" "ouncil o 1ygiene and (ublic1ealth e/pose created @oard o 1ealth,U.S. turning point


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%arly U.S. public health initiatives motivatedmore by economic than humanitarianconcern

US(1S est. 7:F? as 4arine 1ospital Service tocare or ill sailors in seaport cities0 7?:94arine1ospital system reorganized as national systemwith $Surgeon eneral' in charge ;Dept. o theIreasury>

7??F* "ongress est. (ublic 1ealth Service"ommissioned "orps, a mobile physician corps toassist with disease control 3 health protection


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"evelopment of ,-!- Public Health .Government/!upported !ervice* $%

7?F7* Staten -s. 4arine 1ospital labmoved to D.".0 orerunner o the -1

7F7J* 4arine 1ospital Servicerenamed U.S. (ublic 1ealth Service0became maor agency o D11S

7FAA* Hederal %mergency Relie !ct0

optional ederal aid to states or acute3 chronic medical 3 nursing care,obstetrics, drugs 3 supplies


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7F:9s* ational -nstitutes o 1ealthcreated or disease, occupational health 3saety research

7F:F* Dept. o 1%< renamed Dept. o1ealth 3 1uman Services0 educationmoved to its own department

J97A* D11S budget K FB7 @0 healthprotection, promotion, provision o health,other human services to vulnerablepopulations0 A99 programs through 79

operating divisions ;L8G,999 employees>


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"HH! Operatin("ivi*ion* $1% ational -nstitutes o 1ealth ;-1>* 7?

health institutes, ational 6ibrary o4edicine, ational "enter or

"omplementary 3 !lternative 4edicine0A9,999 research proects

Hood and Drug !dministration ;HD!>* ood,cosmetic, drug, biological product saety

"enters or Disease "ontrol and (revention;"D">* monitors disease trends, disease,inury investigations and control measures


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"HH! Operatin("ivi*ion* $&% -ndian 1ealth Service ;-1S>* operates hospitals,

health centers, health stations serving 7.G 4 oG99M tribes

1ealth Resources and Services !dministration;1RS!>* multiple programs serving needy0HN1"s0 health proessional training orunderserved areas

Substance !buse and 4ental 1ealth Services

!dministration ;S!41S!>* Ouality 3 access tosubstance abuse prevention, addition treatment,mental health services, 1-P2!-DS services


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"HH! Operatin("ivi*ion* $0% !gency or 1ealthcare Research and

Nuality ;!1RN>* research to improveOuality, reduce costs, improve patient

saety0 evidencebased research "enters or 4edicare 3 4edicaid Services

;"4S>* administers these and "hildrens1ealth -nsurance (rogram

!dministration or "hildren and Hamilies;!"H>* 89M programs, e.g. 1ead Start,child support enorcement, I!H, domestic

violence, adoption, oster care


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"HH! Operatin("ivi*ion* $% !dministration on !ging ;!o!>* administers

ederal programs under the 5lder!mericans !ct, e.g. meals on wheels,

community level programs to supportolder persons and their caregivers.


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eteran* Admini*tration$1% Hirst established or disabled, indigent "ivil


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"epartment of "efen*e )ilitar+Health !ervice Pro(ram

Hederal support or direct care 3support services or L?.7 4 militarypersonnel 3 dependents, military

retirees, amilies 3 others entitled


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!tate*3 Role* in PublicHealth "ontribute L7BQ o total national

health care e/penditures 5perate or support hospitals, support

medical schools, operate mentalinstitutions0 health departments thatconduct inectious disease monitoring 3control, support primary 3 preventivehealth services at state and local levels


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Cit+ and Count+ Role* in PublicHealth

1ealth departments* direct services,primary prevention, epidemic surveillanceand control

7999M public hospitals and health systemsprovide $saety nets' 3 servicesunattractive to other hospitals

"risis response or public health

emergencies

Special services or medically needy 3 lowincome populations


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"ecline in In4uence of PublicHealth !ervice $1%

Despite impressive contributions,unding always competed or morehighly valued demands o health

sector 7F89s* proessionals, political leaders,

media criticized grants to state, localagencies as ine#ective

ew, important programs assignedto nonpublic health agencies*4edicare, 4edicaid, 1ead Start,

others assigned outside o public


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"ecline in In4uence of PublicHealth !ervice $&%

7F:9s* ended $"reative Hederalism'* i/onopposed ederal, state, local public healthsystem0 ederal responsibilities moved tostates

7F?9s* Reagan continued more e/trememeasures0 bloc+ granted Hederal unds0decline o governments organized system opublic health accelerated

7F?G* -54 Report on status o public health*ailures o policy development0 politicization opublic health agencies0 ambiguousresponsibilities among levels o government


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Re*pon*ibilitie* of the PublicHealth !ector $1%

Healthy People 2000, National HealthPromotion and Disease PreventionObjectives: ;response to 7F?? -54

concerns% F9Q o population should be

served by local health departmentsthat carry out core public healthunctions* !ssessment, (olicyDevelopment, !ssurance


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Re*pon*ibilitie* of the PublicHealth !ector' Core 5unction*

7. !ssessment* collect, analyze data to defnepopulation health status, Ouantiyinge/isting or emerging health problems

J. (olicy development* generaterecommendations rom data to intervene,mobilize public 3 community organizations

A. !ssurance* government public health

agencies ensure basis health deliverycomponents are in place


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16 E**ential Health "epartmentRe*pon*ibilitie*

7. 4onitor health status, solve communityproblems

J. Diagnose 3 investigate health problems 3

hazardsA. -norm, educate, empower people about

health issues

B. 4obilize community partnerships 3

actions to solve health problems

G. Develop policies 3 plans to supportindividual 3 community health e#orts


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16 E**ential Health "epartmentRe*pon*ibilitie*

8. %norce laws and regulations to protect healthand ensure saety

:. 6in+ people with personal health resources 3ensure health care availability

?. (rovide competent public 3 personal healthwor+orce

F. %valuate e#ectiveness, accessibility, Ouality o

person and populationbased health services79.Research or new insights 3 solutions to

environmental health problems


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Re*pon*ibilitie* of the PublicHealth !ector $2%

Healthy People 2010* recognized that 1(J999 ailed to meet ?GQ o A7F targets01( J979 noted progress in :7Q o targets,

but $disparities not changed or ?9Q oobectives and increased or 7AQ.'

1( J9J9 continues J979 obectives withmany additional topics, e.g. adolescent

health0 gay, lesbian, bise/ual, transgenderhealth0 global health, genomics, olderadults


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Relation*hip of Public Health andPrivate )edicine $1%

"omplementary roles with di#ering pointso attention* preventive or populationgroups versus curative or individuals

(ublic health and clinical medicine$separated' in the 7FB9s as medicinepursued scientifc, hospitalbased services,less attention to community health Separation continued with pac+ed medical

school curricula and aculty lac+ing publichealth e/perts


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Relation*hip of Public Healthand Private )edicine $&%

(ersistent discord between public health andclinical medicine*

(ublic health eOuated with governmentbureaucracy

(ublic health lin+ed with low income populations (rivate 4Ds eOuate patient service to

$community service,' paid only or $activepractice'

(ublic health accomplishments in inectiousdisease 3 sanitation $invisible,' so not $politicallyattractive'

!"! may help close gap with populationbasedapproaches aligned with reimbursement incentives


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Oppo*ition to and Cooperation7ith Public Health !ervice*

Struggles with limits o public healthmandate Hears o $socialized medicine0'

intrusions o government services intoprivate practice0 mandated inectiousdisease reporting usurped patientsconfdential physician relationships

Synergistic private2public medicine !dult and child immunizations

Disease screening programs partner

public health initiatives with private


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Re*ource Prioritie* 5avor Curative)edicine over Preventive Care

7F?77FFA* %mergence o 1-P2!-DS0reemergence o tuberculosis, measles0escalating substance abuse, violence,

teen pregnancyIotal U.S. health e/penditures increased

J79Q0 public health unding declined JGQ

-nvestments in hightech curative e#orts

;e.g. unding or neonatal intensive care>ar outstrip more e#ective, ar less costlypreventive strategies


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Challen(e* of "i*enfranchi*edPopulation*

4aor causes o disease, disabilities amongdisenranchised individuals result rommultiple causes not amenable totechnological remedies

%vidence that behavior 3 environment areresponsible or :9QM o avoidablemortality0 e#ective interventions not

integrated into medical care 6ac+ o reimbursement or liestyle,

behavioral interventions in clinical medicine


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Public Health !ervice* ofoluntar+ A(encie* $1%

(rivate notorproft agencies shareresponsibilities with government orflling service gaps or needy and

special populations (roviders* hospitals, nursing homes,

home care, medical 3 vocational

rehabilitation, hospice,disease2conditionorientedorganizations, e.g. asthma,

reproductive health, etc.


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Public Health !ervice* ofoluntar+ A(encie* $&%

otorproft oundations supportcommunity and population healthinitiatives to stimulate research,

demonstration proects andpublic2private2academic partnerships


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Chan(in( Role* of Governmentin Public Health

Hederal, state, local governmentinvolvement in public health remainssubstantial at all levels

Roles are evolving with system reorms0 manystates now combine health and social servicesagencies or particular population groups

ational and state support o public healthactivities has moved toward increasedprivatization in line with mar+et consolidationsand e/pansion o orproft enterprises


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Public Health in an Era ofPrivati8ation

Declines in public health unding andconstrained state and local budgetsled to downsizing o state and local

health departments and serviceoutsourcing

1ealth departments maintain

essential services but oten atconsiderably reduced levels


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Government Challen(e* inProtectin( Public Health $1%

State and local defcits result indownsizing public health serviceswhile business leaders recognize

importance o healthy wor+erpopulations

Ierrorist attac+s o J997 spar+ed

ederal attention to public health$deense' with new Dept. o1omeland Security ;D1S>&JJ new

and e/isting agencies


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Government Challen(e* inProtectin( Public Health $&%

D1S activities were disointed acrossG9 state and A,999 local agencies o nationally consistent plans and

systems development ;evident indisasters such as atrina>

States and localities constructed

individual goals and priorities Si/ years o postF77 preparedness

unding ailed to yield comprehensive,national capabilities


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Public Health Ethic* $1%

7F?? -54 report, The Ftre o! PblicHealth, spawned "D"s 7FF9creation o the ational (ublic 1ealth

6eadership -nstitute ;(16-> convene public health leaders to

address -54cited defciencies 3

collaborate to meet challenges (16- graduates created the $(ublic

1ealth 6eadership Society0' identifedneed or a public health code o ethics


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Public Health Ethic* $&%

"ode o ethics recognized that ensuring andprotecting public health is inherently moral0code draws rom ethical principles o humanrights, distributive ustice, duty to ta+e action

as an ethical motivation.

Di#ers rom medical ethics concerned withindividuals, public health code concernedwith institutions interactions withcommunities.

!(1! adopted code in J99J0 ollowed bymany others


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Public Health Ethic* $0%

Iwelve ethical principles ;synopsis> re)ectinstitutions relationships with communities*

7. !ddress causes o disease, aiming to

prevent adverse health outcomesJ. Respect rights o individuals in the

community

A. %nsure input rom community members

B. !dvocate or and empowerdisenranchised

G. See+ inormation or e#ective policies 3

programs


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Public Health Ethic* $%

Iwelve ethical principles ;synopsis>, contd

:. !ct in a timely manner

?. Respect diverse values, belies, cultures

F. %nhance the physical and socialenvironment

79.(rotect confdentiality0 ustiy e/ceptions

77.%nsure proessional employee competence

7J.@uild public trust and institutione#ectiveness


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ACA and Public Health/)a9orProvi*ion* $1%

ational (revention, 1ealth(romotion and (ublic 1ealth "ouncil;the "ouncil>0 headed by Surgeon

eneral0 7: ederal agencies, JJmember presidentially appointed!dvisory roup

Hour directions* 7> building healthy, saecommunities, J> e/panding clinical andcommunity preventive services, A>empowering healthy choices, B>

eliminating health disparities


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ACA and Public Health/)a9orProvi*ion* $&%

"ouncil J97J report outlined G9 +eyindicators aligned with evidencebased datasources on the B +ey directions

(revention and (ublic 1ealth Hund* thefrst mandatory unding stream toimprove public health0 K :@ fscal J979J97G0 KJ @ each succeeding year0

restrain costs, improve health 6ocal, state, ederal programs* curb tobacco

use, increase primary2preventive care access


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(ublic 1ealth Hund, contd 6ocal, state, ederal programs* curb

tobacco use, increase

primary2preventive care access 1elp states and local communities

respond to public health threats andoutbrea+s

-ncrease access to clinical preventiveservices* 4edicare coverage or annual

wellness2preventive services visits


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ACA and Public Health/)a9or Provi*ion*$%

-ncrease access to clinical preventive services, contd

-ncrease state 4edicaid unding or preventiveservices and incentives or benefciaries participationin healthy liestyles programs

-ncrease unding or HN1"s

(revention and (ublic 1ealth -nnovation

Hederal health program unding to collect and reportdata on indicators o disparity

Hunding or education, technical support or wor+placewellness


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(revention and (ublic 1ealth -nnovation,contd

"D" support or state, local, tribal

agencies improvement in surveillanceo and responses to inectious diseases,other conditions a#ecting communityhealth

1ealth "are


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ACA and Public Health/)a9orProvi*ion*' Health Care :or;force

Recognizes shortages o primary careand public health proessionals inunderserved areas

%stablishes National Health "or#!orce$ommission* review current2proectedneeds, recommend ederal policies to

align with needs0 competitive grantsor statelevel wor+orce planning anddevelopment strategies


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Student loan repayments or publichealth students 3 allied healthproessionals wor+ing with underserved

populations in public health agencies ational 1ealth Service "orps

scholarships and loan repaymentswithin US(1S or $Ready Reserve "orp'to respond to national emergencies

K G9 4 or nursemanaged health clinics


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Iraining programs in cultural competency,public health, disabled populations

rants or community health wor+ers

Hellowship training support or proessionalsin state and local health departments inapplied epidemiology, public healthlaboratory science, inormatics

"reates US(1S (ublic 1ealth Sciences(rogram to train health proessionals inpublic health disciplines


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"reates US(1S (ublic 1ealthSciences (rogram to train healthproessionals in public health

disciplines Reauthorizes programs to attract

minority applicants to health

proessions with commitment to wor+in underserved areas

ACA and Public Health


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ACA and Public Health/!ummar+ !"! recognizes and supports centrality

o public health concepts, principles andpractices in improving !mericans health

status !"! provisions respond to needs or

emphasis on integrated systems opublic and private health care

5pportunities or public health andorganized medicine to collaborate ininnovative ways


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The 5uture

4aor challenges in changing e/istingperceptions and practice patterns0 a newvision or public health role needed to

change entrenched behaviors andorganizational commitments

(revention emphasis tied to reimbursementmay be +ey to advancing needed change

5pportunities or new, unctionalrelationships between public health andmedicine

health care usa chapter 11

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