5. Provision of services
nsured individuals tend to enter the health-care system through a PCP, though with some kinds of insurance (PPO) individuals may go directly to a specialist. Uninsured individuals often do not have a regular PCP, but instead visit CHCs (which provide primary care for low-income, uninsured and minority populations) and hospital emergency rooms for their health care, which hinders continuity of care. Due to OOP costs they may be reluctant or unable to seek out specialty, surgical, or inpatient care unless they need emergency care; EDs in hospitals that receive payment from Medicare (which is nearly all hospitals in the United States) are required by law to provide care to anyone needing emergency treatment until they are stable. Retail clinics (in pharmacies or large stores) are also emerging as places to go for treatment of minor medical conditions.
The number of acute inpatient (hospital) discharges and length of stay have fallen over the past decades, with more acute-care services, such as surgery, being performed on an outpatient basis. For example, in 2010 more than three-quarters of all surgeries were provided in an outpatient setting. Mental health services have also shifted predominantly from inpatient to outpatient, accompanied by substantially increased use of pharmaceuticals and reduction in provision of psychotherapy and mental health counselling. The utilization of post-acute-care services such as rehabilitation, intermittent home care, and sub-acute care has increased over the past decades due to the financial need for hospitals to discharge patients not requiring acute care. Palliative care is received mostly through hospice services, either in the patient’s home, or in a hospital, nursing home or other institutional setting. Hospice care has increased due to an expansion of Medicare benefits in 1983. The informal caregiver (usually family or friends) plays an important role in United States health care; 23% of Americans provide some form of informal care.
Pharmaceuticals are highly utilized in the United States compared to other industrialized countries, and their use has been growing. The use of complementary and alternative medicine (CAM) is also growing in the United States. Although physicians initially opposed the use of CAM, their stance has softened due to its popularity with the public and some scientific evidence regarding the efficacy of certain therapies. Patients must pay out of pocket for most forms of CAM.
Vulnerable populations in the United States include racial and ethnic minorities, those with low income, the uninsured, the disabled, the homeless, women, children, persons with HIV / AIDS, the mentally ill, the elderly, and those living in rural areas. Federal, state, and private agencies have programmes for reducing disparities in health and health care for these populations. Populations that have special access to health services include American Indians and Alaska Natives (AIANs), military personnel, veterans, and those who are institutionalized, such as prisoners.
United States public health is decentralized, with the main locus of power at the state level. The actual public health structures at the state level vary significantly; in some states, public health functions are further decentralized (e.g. to county level). At federal level, the United States Public Health Service (USPHS) brings together eight federal public health agencies (including the CDC, the FDA and the NIH). Federal, state and local public health services have been underfunded, and tend to be driven by immediate concerns; for example, as concerns rose over terrorist attacks in the United States, much of the public health funding and services switched to terrorism preparedness, leaving holes in other areas of public health.
5.1 Public health
Public health focuses on promoting health at the population level through investigating and intervening in the environmental, social and behavioural factors in health and disease. It deals with prevention and health promotion rather than treatment of disease and recovery of health, which is the domain of medical care. It attempts to influence social, economic, political and medical factors that affect health and illness (Shi & Singh, 2012). The three core functions of public health defined by the IOM are assessment, policy development and assurance (Salinsky, 2010). The 10 essential services identified by the APHA that correspond to these core functions are listed in Box5.3. (Salinsky, 2010).
5.1.1 Organization of public health services
Public health is promoted mostly through public agencies, primarily at the state level, but some private agencies also play a role. At the federal level, public health services are headed by the USPHS, a division of the HHS. The USPHS is comprised of eight agencies listed in Box5.4 (U.S. Department of Health and Human Services).
The AHRQ, HRSA, NIH and Substance Abuse and Mental Health Services Administration (SAMHSA) are the chief federal agencies for funding health-care programmes and research. The AHRQ funds research on quality, costs and administrative issues in health care, while the NIH funds biomedical and clinical research primarily. Although the AHRQ and NIH are considered to be part of the USPHS, in reality the bulk of their research is on medical, not public health, issues. The HRSA funds programmes and research on the indigent, uninsured, rural residents, other special need populations, and the health-care workforce. Another major function of the HRSA is to collect data on the health-care workforce. The HRSA’s functions have more of a public health purpose in that they help assure adequate health-care resources, yet as with the AHRQ and NIH most of these resources go into providing medical care. The SAMHSA funds programmes and conducts its own studies into the prevention and treatment of alcoholism, substance abuse and mental illness. The SAMHSA’s funding is delivered mostly through block grants and contracts with state health agencies.
The Agency for Toxic Substances and Disease Registry (ATSDR) monitors and protects against exposure to hazardous wastes, and works to minimize ill health effects of hazardous waste emergencies and pollution from hazardous wastes. The CDC is responsible for the surveillance, identification, and prevention of disease and injury in the United States, and provides assistance to other countries and international health organizations regarding these health concerns. Major components of the CDC include identification and prevention of infectious and chronic diseases (including HIV / AIDS and sexually transmitted disease (STD) prevention), injury prevention, immunization, health promotion, environmental health, occupational safety and health, emergency and terrorism preparedness, and cancer screening. The CDC also funds and collects data for public health research in these areas.
The FDA oversees the Federal Food, Drug, and Cosmetic Act, several related public health laws, and food safety (along with the USDA). Areas supervised include new medical devices, experimental drugs, biological products, cosmetics, food additives, food labels, domestic and imported foods (except for meat and poultry) and food given to livestock. The USDA is responsible for meat and poultry safety (more information on the FDA, CDC and other HHS agencies can be found in sections 2.3 and 2.8).
The Indian Health Service (IHS) provides public health services to American Indians and Native Alaskans, primarily on Indian reservations and in Eskimo villages. More than half of all American Indians, however, do not live on reservations and are not eligible for these services. When resources are available, services include preventive, ambulatory and hospital care, community health, alcohol programmes and rehabilitative services.
At the state level, all 50 states have state health agencies that carry out public health efforts. States legally have the greatest authority for carrying out public health. While influencing state and local practices, federal laws tend to give states the leeway to determine the scope and amount of services and to establish the vehicles for providing those services.
As a result, the organizational structure of state public health agencies and the services provided by those agencies vary significantly across the states, making general descriptions difficult. Public health functions can be the sole domain of one state agency or part of the function of an agency that is also in charge of social services, licensing and regulation of acute and long-term care, the administration of Medicaid or insurance regulation (Salinsky, 2010). Public health functions can also be spread over more than one state agency or can be performed in partnership with private organizations. Public health functions administered in public agencies outside the main state health agency include the regulation and inspection of health-care facilities, the licensure of health professionals and the control of disease vectors such as mosquitoes. States also differ with regard to whether the relationship between state and local public health agencies is decentralized, centralized or a hybrid of the two. In more decentralized models, local public health agencies have greater administrative control.
Many public health functions are delegated to local public health agencies (usually called “health departments”) within that jurisdiction. Jurisdictions can be at the county, city, town or township levels (Salinsky, 2010). According to Salinsky (2010) most local health departments (60%) are at the county level, 18% cover a city, town or township, 11% are joint city–county jurisdictions, and 9% are multicounty.
5.1.2 Public health services
Communicable disease control
Control of communicable diseases is carried out by local and state health agencies in collaboration with the CDC. Local and state agencies conduct surveillance of communicable diseases, and collect and analyse the data. Both private and state laboratories analyse specimens. Examples of communicable diseases of public health concern for becoming epidemics or pandemics are meningitis, West Nile Virus, Hanta Virus, influenza strains such as H1N1, and the plague. The CDC is notified of unusual or alarming outbreaks or trends. Outbreaks of communicable diseases, once reported to the CDC, are further investigated by this agency. Control and prevention measures are then implemented by the CDC in collaboration with the affected area(s). For communicable diseases that are endemic, such as STDs and tuberculosis, local public health departments offer both screening and treatment (see section Health promotion and prevention services below) (Salinsky, 2010).
Environmental hazards are prevented, detected and corrected by federal, state and local public health agencies, or in some states an environmental agency. At the federal level the ATSDR is responsible for identifying people at risk of exposure to hazardous substances, evaluating the risk of hazardous substances in the environment, and preventing or minimizing the effects on health. The types of hazard typically controlled are air pollution, contaminated food and water, chemical spills, radon gas, mosquitoes and other disease vectors (Salinsky, 2010; CDC, 2010).
Emergency and terrorism preparedness
Efforts to prepare for emergencies and terrorism are led by the CDC and the HHS Office of the Assistant Secretary for Preparedness and Response, which publish protocols for action for state and local government agencies. However, each local agency is responsible for developing a customized plan based on CDC protocols, and state governments play a key role by devoting resources to local preparedness planning (Salinsky, 2010). Preparedness and response efforts include surveillance, laboratory testing, outbreak investigation, and the treatment and quarantine of the population. Plans must have a coordinated emergency medical response. In the event of an incident, state and local agencies are responsible for implementing the plan in collaboration with the CDC.
Promotion of occupational health
Promoting of occupational health is carried out by the National Institute of Occupational Safety and Health (NIOSH), a part of the CDC, and the OSHA, a part of the United States Department of Labor (CDC, 2010). The NIOSH funds research, investigates workplace safety, and provides information, education and training in occupational safety and health, while the OSHA is responsible for developing and enforcing workplace safety and health regulations. State health agencies are also involved since they may be the first to be called regarding a safety issue. The NIOSH encourages employers and employees at all worksites to report possible safety violations. When a possible occupational hazard is reported, the NIOSH’s Health Hazard Evaluation Program investigates the claim. The NIOSH employs a research-to-practice philosophy, in which it encourages the translation of research findings, technologies and information into prevention practices and products that can be adopted in the workplace. The NIOSH also engages in prevention through its Total Worker Health Program, which combines occupational safety with health promotion to prevent illness and injury. This combination of research, regulations, prevention and surveillance comprises the core occupational health functions of the United States public health system.
Surveillance of population health and well-being
Surveillance involves the collection, processing and maintenance of data on the following population measures: vital statistics (e.g. births and deaths); demographic characteristics (age, sex, race, ethnicity, education, employment, income and residence); childhood immunizations; behavioural risk factors; incidence of cancer, trauma and occupational injuries; communicable, acute and chronic diseases; insurance coverage; and health-care utilization and expenditures (Centers for Disease Control and Prevention, 2010b). State agencies collect much of this data through provider reports, hospital discharge databases, registries, and population surveys (Salinky, 2010). Federal agencies contributing to this surveillance include the AHRQ, BLS, CMS, National Cancer Institute, SAMSHA, and the United States Census Bureau (Centers for Disease Control and Prevention, 2010b). Private agencies that contribute data include various medical associations and the Dartmouth Institute. The data from these agencies are shared with the CDC, which additionally sponsors several surveys that collect data on ambulatory care, hospital inpatient care, home and hospice care, nursing home care, vital statistics, immunizations, nutrition and population health (Centers for Disease Control and Prevention, 2010b). For example, the CDC’s population health survey – the National Health Interview Survey (NHIS) – collects information on illnesses, injuries, activity limitation, chronic diseases, health insurance coverage and utilization of health care. United States data are also compared internationally using OECD data. The CDC places much of this data, aggregated to the national level, into a publicly available (on the Internet) annual report entitled Health, United States (Centers for Disease Control and Prevention, 2010b).
Health promotion and prevention services
These services are funded by federal and state governments while local health departments and CHCs provide the services. Most local public health departments provide screening and treatment for communicable diseases such as STDs and tuberculosis. Many also provide services to high-risk women and children (low income, special health-care needs). Services may include perinatal home visits, well child clinics, developmental screening, and women, infants and children (WIC) nutrition counselling. Some other prevention services provided are: adult and childhood immunizations; screening for diabetes, cardiovascular and other chronic diseases; smoking prevention and cessation; and prevention of HIV / AIDs, unintended pregnancy, obesity, inactivity, substance abuse, injuries and violence. Supported educational activities include media campaigns, outreach to high risk groups and general population education. Some activities are conducted in partnership with NGOs, non-health-care related local government agencies or state health agencies. The amount of resources devoted to health promotion and prevention activities and the engagement of agencies varies by state and locality. Larger local health departments are more likely to provide a comprehensive set of services (Salinsky, 2010).
Public health screening programmes
There is no national public health screening programme in place in the United States, and screening programmes vary from state to state. State and local departments of health may screen for communicable diseases such as STDs and tuberculosis, newborn congenital diseases, and chronic diseases such as diabetes and cardiovascular disease. Screening programmes are also available in CHCs, doctors’ offices and retail health-care settings (shopping malls, general stores, etc.). Outreach to the most vulnerable populations is always an issue, however. Many other diseases are screened in the United States (for example, breast and colon cancer) but whether these are offered to the individual patient is up to the discretion of the PCP and cannot be considered part of a public health effort except to the extent that there is public health education regarding the need to be screened.
Services funded or directly provided by state government include mental, correctional and child health services. Some state governments engage in the direct provision of mental and correctional health services, while most delegate the services to private agencies. Most states directly provide services for children with special health needs.
Licensing, regulation and planning of health-care facilities and workforce
These functions are generally under the jurisdiction of state and local public health agencies. These agencies inspect and license health-care facilities. State agencies license health-care professionals, and certify the non-professional health-care workforce (see also section 4.2.6). State agencies may also measure the performance of health-care providers and facilities, publish quality report cards based on those measures and engage in other activities to improve the quality of health-care services. Other organizations that measure and publish quality data on providers are federal agencies such as CMS (through its Hospital Compare and other reports) and the AHRQ (through its National Health Care Quality Report), and numerous private agencies such as the NCQA. Some private agencies such as the Joint Commission, monitor quality but do not publish results. Most state health departments also inspect and license food processing facilities, solid waste removal services and other health-related facilities (see sections 2.5, 2.6 and 2.8 for more information).
5.1.3 Accessibility, adequacy and quality of public health services
In addition to the observations above about the organization and functioning of the United States public health system, federal, state and local services have been underfunded, resources at the local level are inadequate, and services tend to be driven by immediate concerns and political expediency rather than a long-term vision (IOM, 1988, 2003; Baker et al., 2005; Salinsky, 2010). The public health workforce (as a ratio of public health workers to population) has declined over a 30-year period (Baker et al., 2005) and is insufficiently trained (IOM, 2003). Many agencies operate with outdated facilities and technologies, including informatics (Baker et al., 2005). Until the early 2000s many agencies had fragmented information systems with limited or no access to the Internet and electronic mail, leading to lack of population-based data on public health diseases and exposures (IOM, 2003). The anthrax and West Nile outbreaks overwhelmed the monitoring capabilities of laboratories. Funding and resource availability has also been noted to vary substantially by locality, so that some agencies have sufficient resources while others are significantly lacking (Mays & Smith, 2009). In 2005, for example, per capita spending by local agencies ranged from $1 to $200 (Mays & Smith, 2009).
It has also been difficult to systematically prioritize the allocation of services based on scientific analysis of needs (IOM, 2003; Salinsky, 2010). Instead, activities have been prioritized according to immediate public health threats and political expediency. For example, as concerns rose over terrorist attacks in the United States, much of the public health funding and services switched to terrorism preparedness, leaving holes in other areas of public health (Editorial, 2005). As a consequence, it is thought by some that the focus on terrorist attacks contributed to the inadequate response to Hurricane Katrina (Editorial, 2005). This failure to develop an overall evidence-based direction for public health services may play into the fragmentation of services just discussed.
A 2003 report by the IOM summarized the United States public health system as having “incomplete domestic preparedness and emergency response capabilities, and communities without access to essential public health services”, which left the population vulnerable not only to “exotic germs and bioterrorism” but also to “social and other environmental conditions (that) undermine health, including toxic water, air, and housing; inaccurate and confusing health information; poverty; a lack of health care; and unequal opportunities for health” (p. 3).
Public health improvement initiatives began in the 1990s in response to the 1988 IOM recommendations and the Healthy People 2000 objective of having 90% of the population served by effective public health services by the year 2000 (Scutchfield, Mays & Lurie, 2009). The Public Health Improvement Act enacted by Congress in 2000 called for a plan to assure the preparedness of every community in the nation and allocated additional funds to upgrade public health programmes (Baker et al., 2005). Professional associations, such as the National Association of County and City Health Officials (NACCHO) and the CDC, assessed local public health services and developed guidelines, strategies and performance measures (Scutchfield, Mays & Lurie, 2009).
These developments succeeded in improving the access to and quality of public health services. Overall funding increased for several years, and the coordination, planning and delivery of services improved. But lack of funding threatens future progress. Budget cuts in state funding, which began before the 2008 recession and have deepened since, threaten the progress made to date (Baker et al., 2005; Calmes, 2011). The ACA established a Prevention and Public Health Fund dedicated to public health and disease prevention (Haberkorn, 2012) but it too is undergoing cuts.
The Biden Administration is taking strong measures to deal with the COVID-19 pandemic. Among the first actions in January, the administration directed public health agencies to strengthen workforce safety protections and provide guidance to schools and universities about safe reopening. A health equity task force was established to reduce disparities in COVID care. Federal agencies were directed to secure and make available pandemic supplies, and National Guard availability for pandemic assistance was extended. The administration has asked all American to wear masks and requires compliance with COVID-19 safety measures on federal property and with federal workers.
The administration is addressing the affordability of, and access to, COVID-19 treatments, and supports the development of new treatments. Most notably, President Biden has worked to get the COVID vaccines out as quickly as possible and to make them free to all.
The new administration has taken a scientific approach to leadership, emphasizing the importance of collecting and using pandemic-related data, setting up a scientific advisory board with regular briefings, and removing political interference in the Centers for Disease Control and Prevention and other public health operations. Under the Biden Administration the U.S. has rejoined the World Health Organization.
In March 2021, Congress finalized relief of $1.9 trillion for those economically affected by COVID, and President Biden signed it into law. The legislation provides direct payments of up to $1,400 per person to most Americans, a $300 weekly increase in jobless benefits through September 2021, and an extension of the child tax credit for one year.
These actions have the potential to improve the public health system in the U.S. by promoting trust in public health experts, eliminating political interference in public health science, improving emergency response systems, and increasing resources to public health, which has seen a drop in federal funding over the past decades. To further strengthen public health the administration plans to review actions from the previous administration that were damaging to the environment or public health.