Catapulting the Chasm: Or How to Avoid Wasting a Perfectly Good Fiscal Disaster

The nation once again is on the precipice of financial catastrophe, but have we overlooked public health? Juxtaposed against one another, the comparison of health care with public health—one largely overutilized, expensive, and underperforming, the other responsible for eradicating diseases and providing safe food and water—cries out for thoughtful fiscal recalibration. We have examined the recent Institute of Medicine report on public health financing and made actionable recommendations for sustainable public health financing.THE NATION HAS ONCE AGAIN avoided going over the precipice of yet another cataclysmic financial catastrophe, affectionately termed the “fiscal cliff.” This manmade disaster resembles others in our recent history including the so-called debt ceiling compromise that set the stage for the current crisis and is scheduled to be revisited in early 2013. Although these 2 events share the potential to produce a US fiscal nightmare and a date certain for events to begin unfolding, there is another fiscal cliff our country has waltzed over in virtual slow motion with equally dire consequences.Over recent decades we have spent lavishly on health care, outstripping expenditures of other developed nations by more than twofold, even as other societal needs have been overlooked.1 Yet the return on our present $2.7 trillion investment in health has been extremely modest.2 Moreover, even a nation as wealthy as ours incurs opportunity costs. The vast resources committed to health care are unavailable to be invested elsewhere: in education, social programs, and vibrant communities—the very investments in social and environmental determinants of health that pay returns in the form of health dividends. Worse, not only do we lead the planet in health expenditures, but we also lag behind most developed nations in health outcomes for communities as well as individuals.2 In short, from a value proposition perspective, we spend too much and gain too little.Even as health care expenditures skyrocket, accounting for an ever growing share of the projected sea of red ink that is the federal budget forecast, public health expenditures stagnate or decline.3,4 In fact, spending on governmental public health is a rounding error considering the size of the overall health budget, a mere fraction estimated at less than 2.5% of total costs.5 Ironically, public health has been triumphant, accounting for the major proportion of US life expectancy gains achieved in the 20th century.6 Juxtaposed against one another, the comparison of medical care with public health—one overutilized, expensive, and underperforming, the other responsible for eradicating infectious diseases, decreasing by half the incidence of cardiovascular disease, and providing safe food and water among other societal advances—cries out resoundingly for a thoughtful fiscal recalibration.     

The Role of Historically Black Colleges and Universities in Training the Health Care Workforce

Historically Black colleges and universities (HBCUs) continue to be overlooked as a resource to address health care workforce shortages and growing needs for a diverse health workforce, despite our commitment as a nation to health equity and eliminating health disparities.Health workforce graduation rates help illuminate the roles of institutions of higher education in meeting workforce needs. Effective approaches to eliminating disparities invest and leverage resources that address our health workforce and diversity deficits.We must recognize HBCUs as a valuable resource for educating underrepresented groups as health professionals. Increasing resources and enhancing support for building the capacity of HBCUs to produce health professionals is vital to addressing disparities and achieving health equity for our nation.People of color are disproportionately represented in health professional shortage areas. They represent more than 25% of the total population, but only 10% of health professionals.Historically, people of color have been underrepresented in all of the primary health professions. According to one source, between 2000 and 2006 the profession with the highest proportion was pharmacy (9.9%) and with the lowest was dentistry (5.4%). Public health was the only profession studied that had a substantial increase in African Americans during this period. In medicine, dentistry, nursing, and pharmacy, the percentage remained virtually unchanged.1 In 2006, the Association of American Medical Colleges called for a 30% expansion of the total enrollment in medical schools.2In 1996 there was one dentist for every 1700 persons but only one African American dentist for every 6150 African Americans. In 2002, an estimated 27 million persons lacked a dental provider, and 4300 more dentists were needed in the United States.3The Health Resources and Services Administration estimates that the shortage of nurses will reach 29% by 2020. In 2000, only 4.9% of registered nurses were African American.4 The capacity for training nurses is severely inadequate. The National League for Nursing estimates that 99 000 applicants to nursing programs were turned away in 2008 because of inadequate capacity.5In 2000, only 4.7% of pharmacists were African American and 3.2%, Hispanic. The pharmacist shortage decreased in the first decade of this century, and projections of its future magnitude differ.6 Effective July 1, 2007, the Accreditation Council for Pharmacy Education determined that the PharmD degree is the sole professional practice degree for pharmacy in the United States. It is too soon to determine the impact of this major modification in the pharmacy profession.The ratio of public health workers declined from 220 per 100 000 population in 1980 to 158 in 2000.7 This decline is exacerbated by the absence of formal training in public health among four out of five public health workers. Approximately half of all public health workers will be eligible for retirement within the next decade. This looming insufficiency is most dramatic among public health nurses, who were 39% of public health workers in 1980 but were 17.6% in 2000. States report that the shortage of epidemiologists is approximately 50% and that 20 000 more public health laboratory professionals are needed. Although environmental professionals account for only 4.5% of the public health workforce, the need for such expertise is growing.8The Integrated Postsecondary Education Data System comprises interrelated surveys conducted annually by the National Center for Education Statistics that provide demographic data on graduates.9 We reviewed data from this system from 2000 to 2008 and found information relevant to the role historically Black colleges and universities (HBCUs) can play in achieving the goals of health equity and the health professional education of African Americans.     

Budget- and Priority-Setting Criteria at State Health Agencies in Times of Austerity: A Mixed-Methods Study

Objectives. We examined critical budget and priority criteria for state health agencies to identify likely decision-making factors, pressures, and opportunities in times of austerity.Methods. We have presented findings from a 2-stage, mixed-methods study with state public health leaders regarding public health budget- and priority-setting processes. In stage 1, we conducted hour-long interviews in 2011 with 45 health agency executive and division or bureau leaders from 6 states. Stage 2 was an online survey of 207 executive and division or bureau leaders from all state health agencies (66% response rate).Results. Respondents identified 5 key criteria: whether a program was viewed as “mission critical,” the seriousness of the consequences of not funding the program, financing considerations, external directives and mandates, and the magnitude of the problem the program addressed.Conclusions. We have presented empirical findings on criteria used in state health agency budgetary decision-making. These criteria suggested a focus and interest on core public health and the largest public health problems with the most serious ramifications.The governmental public health enterprise continues to face myriad financial and other challenges, including eroding infrastructure, lack of political support, and increasing health problems associated with behavioral health. Since the 2008 economic downturn, thousands of public health jobs have been eliminated, growth has been stifled, and the public health workforce has continued to shrink because of attrition and retirement.1,2 During times of scarcity, the means of allocating resources is of particular interest and importance. However, the characterization and study of resource allocation decision-making is more common in health care compared with public health, where knowledge is limited, especially among national health care systems in developed nations.3–8 Globally, there is a growing interest in the systematic setting of priorities in health care and public health in developing countries, where funds are in shorter supply.4,9–18 A much greater proportion of total health dollars in the United States are spent on health care compared with public health, which is about 3% of total health spending by some estimates.19 This emphasis on spending for health care has created a dearth in research on setting of priorities and budgets in public health; we are not aware of any studies that have examined criteria use in public health priority setting at state health agencies (SHAs), although a few have examined priority setting in local health departments (LHDs). Two studies in particular indicated that the most important priority-setting criteria employed in LHDs were funding availability, mandates, being the sole provider, the size and scope of consequences, politics, and public interest or acceptability.20,21 In 2011, the Association of State and Territorial Health Officials (ASTHO) released their Profile of State Public Health, Volume 2, providing the first collection of revenue and expenditure data that allowed for meaningful comparisons of public health spending across SHAs. These were the first data available in recent years regarding actual spending by SHAs, but these data sets did not capture processes: how SHAs set budgets and why they give priority to the areas they do. We focused on 1 particular component of the priority-setting process—criteria use—because of the critical role criteria were found to play in setting budgets and priorities more broadly in the course of this study, and as reported elsewhere.22     

Enrolling and Retaining Uninsured and Underinsured Populations in Public Health Insurance Through a Service Integration Model in New York City

Innovative strategies to identify uninsured and underinsured populations are critical to successful enrollment and retention in public health insurance. The New York City Department of Health and Mental Hygiene’s Office of Health Insurance Services has partnered with the department’s Early Intervention Program to implement a Service Integration Model to enroll special needs children, aged 0 to 3 years, into public health insurance. This model uses data from program databases and staff from children’s programs to proactively identify uninsured and underinsured children and facilitate their enrollment into public health insurance. The model overcomes enrollment barriers by using consumer-friendly enrollment materials and one-on-one assistance, and shows the benefits of a comprehensive and collaborative approach to assisting families with enrollment into public health insurance.

KEY FINDINGS

■ Partnerships across government programs and agencies offer opportunities to enroll hard-to-reach populations into public health insurance.■ The Office of Health Insurance Services Service Integration Model has 3 key components allowing for comprehensive and continuous coverage for children with special health care needs: integration of program messages within the Early Intervention Program, data matching with child program data (Early Intervention data, Medicaid data), and incorporation of program staff (Office of Health Insurance Services child benefit advisors) to work directly with parents.■ The combination of access to child program data to identify children and one-on-one assistance to complete public health insurance applications has successfully assisted more than 5000 families in the New York City Early Intervention Program.IN NEW YORK STATE, AN estimated 12.7% of children have special health care needs.1 According to McPherson et al., children with special health care needs are defined as

those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.2 ^(p.138)

The 2005–2006 National Survey of Children With Special Health Care Needs found that 38% of families with special needs children had inadequate health insurance coverage.1 Data indicate that 16% of children with special health care needs did not receive any health care services in the past year; 45% of uninsured children with special health care needs needed at least 1 service not received, compared with 22% of publicly insured children, 19% of children with dual coverage (public and private), and 11% of privately insured children. Services not received included dental care, mental health care, therapies, and specialty care.In New York City, almost 40 000 children per year with a diagnosed developmental delay or disability receive services through the Early Intervention Program—a federal entitlement program for children aged 0 to 3 years. In New York City, the Early Intervention Program is administered through the New York City Department of Health and Mental Hygiene (DOHMH). Programs for children with special health care needs, such as the National Early Intervention Program, have been created to ensure that infants and children with developmental disabilities or delays receive needed services. To be eligible for services, children must be younger than 3 years and have a confirmed disability or established developmental delay, as defined by the state, in 1 or more of the following areas of development: physical, cognitive, communication, social-emotional, and adaptive.3 These children receive services free of charge for developmental disabilities or delays. The Early Intervention Program bills the child’s health insurance if the program is aware of the health insurance status of the child, including Medicaid and private or employer-based insurance. Parents are not responsible for paying for any services received through the Early Intervention Program. However, the Early Intervention Program does not cover services for routine medical care or specialized medical services (non-developmental disabilities or delays).The Office of Health Insurance Services at the New York City DOHMH was created to expand the city’s health insurance enrollment capacity, maximize client choice regarding health plan and provider selection, and promote health care use and preventive health behaviors. Since 2000, the Office of Health Insurance Services has been a New York State–approved facilitated enrollment lead agency in New York City. The New York State Department of Health–facilitated enrollment program provides funding, through a Request for Application process, to community-based organizations and local entities to provide eligibility screening and application assistance services to New York State residents applying for public health insurance.In 2009, the Office of Health Insurance Services assisted more than 10 000 applicants throughout New York City with a 97% enrollment success rate. The Office of Health Insurance Services maintains a presence at 9 New York City DOHMH centers and serves clients throughout the 5 boroughs, from all racial and ethnic backgrounds and with limited English proficiency.The challenge of ensuring that children with special health care needs receive comprehensive and continuous health insurance coverage requires innovative strategies. Although New York State has made considerable progress in reducing barriers to enrollment in public health insurance for adults and children, challenges remain. To maximize comprehensive insurance coverage for children with special health care needs, a Service Integration Model was formed between the Office of Health Insurance Services and the Early Intervention Program at the New York City DOHMH.

INCLUSION OF INFORMATION ON SERVICES PROVIDED BY THE OFFICE OF HEALTH INSURANCE SERVICES TO THE EARLY INTERVENTION PROGRAM

Information about services provided by Office of Health Insurance Services included in Early Intervention Program trainings and print materials“Early Intervention Welcome Letter” to parents“NYC Early Intervention Program Policy and Procedure Manual” for Early Intervention Program provider agenciesOffice of Health Insurance Services brochure and poster for Early Intervention Program provider agenciesLetter to Early Intervention Program providersData MatchingEarly Intervention Program dataNew York State Medicaid dataCensus dataIncorporation of Office of Health Insurance Services Staff to Work Directly With Parents of Children in Early Intervention ProgramOne-on-one in-person or telephone assistanceAvailable in multiple languagesAvailable at hours and locations convenient to parentsEducate families on public health insurance productsHelp them apply for coverage     

A Curriculum for the New Dental Practitioner: Preparing Dentists for a Prospective Oral Health Care Environment

The emerging concept of prospective health care would shift the focus of health care from disease management to disease prevention and health management.Dentistry has a unique opportunity to embrace this model of prospective and collaborative care and focus on the management of oral health.Academic dentistry must better prepare future dentists to succeed in this new health care environment by providing them with the scientific and technical knowledge required to understand and assess risk and practice disease prevention. Dental schools must consider creating career pathways for enabling future graduates to assume important leadership roles that will advance a prospective oral health care system.FEW WOULD ARGUE WITH THE notion that the system of health care in the United States is irrevocably broken.1–8 There continues to be limited access to care, and when care is delivered it is often sporadic, uncoordinated, and fragmented.4 The current health care system focuses on disease management rather than health management and prevention. In many respects, dentistry suffers from the same ineffective approach to care delivery.5–8Dentists, like physicians, are taught to use scientific principles to identify the chief complaint, sort through a series of differentials, and, using diagnostic aids, arrive at a diagnosis and deliver the appropriate treatment. This approach has enabled health professionals to better manage disease, but for the most part it has been ineffective in dealing with the complex nature of chronic illness.1,2 What is missing is a personalized plan for disease prevention and health promotion.2,9,10The emerging concept of prospective health care focuses more on prevention, risk assessment, and preemptive intervention.1–3,10–12 Prospective health care addresses the need to reduce costs, increase efficiencies, and improve patient care, especially for those patients presenting with chronic disease.Dental practitioners will be expected to function in collaborative practice environments with physicians, nurses, pharmacists, public health providers, and social workers.6,13–25 Prospective health care in principle will provide more coordinated care at a lower cost. There is little reason not to embrace a prospective health care environment. The current health care system is increasingly costly and inaccessible to a growing segment of the population. In addition to making better use of existing services, the dental profession must explore new workforce models that help meet the oral health care needs of the growing population of underserved.6–8     

Squeezing Blood From a Stone: How Income Inequality Affects the Health of the American Workforce

Income inequality is very topical—in both political and economic circles—but although income and socioeconomic status are known determinants of health status, income inequality has garnered scant attention with respect to the health of US workers. By several measures, income inequality in the United States has risen since 1960. In addition to pressures from an increasingly competitive labor market, with cash wages losing out to benefits, workers face pressures from changes in work organization.We explored these factors and the mounting evidence of income inequality as a contributing factor to poorer health for the workforce.Although political differences may divide the policy approaches undertaken, addressing income inequality is likely to improve the overall social and health conditions for those affected.Income inequality in the United States is now a common theme in national policy debates, and both major parties are seemingly embracing the need to address it, although their messaging and the degree of importance they assign to the issue vary significantly.1,2 Although income itself and the broader construct of socioeconomic status are known key determinants of health status, income inequality has garnered scant attention with respect to health in general and with respect to the health of US workers specifically.Because income inequality is inexorably linked to employment, a more complete picture of the effects of inequality on health emerges when analyzed through the lens of the working population. Moreover, differences in income are associated with differences in occupations and work environments, potentially exacerbating the overall effect of income inequality on workers’ health.We considered trends in US workforce composition, income inequality, and work organization; how income inequality alone and together with income status affects health; and exemplary issues facing the large and growing health care workforce.     

Strengthening Public Health and Primary Care Collaboration Through Electronic Health Records

Electronic health records (EHRs) have great potential to serve as a catalyst for more effective coordination between public health departments and primary care providers (PCP) in maintaining healthy communities.As a system for documenting patient health data, EHRs can be harnessed to improve public health surveillance for communicable and chronic illnesses. EHRs facilitate clinical alerts informed by public health goals that guide primary care physicians in real time in their diagnosis and treatment of patients.As health departments reassess their public health agendas, the use of EHRs to facilitate this agenda in primary care settings should be considered. PCPs and EHR vendors, in turn, will need to configure their EHR systems and practice workflows to align with public health priorities as these agendas include increased involvement of primary care providers in addressing public health concerns.Electronic health records (EHRs) have great potential to serve as a catalyst for more effective coordination between public health departments and primary care providers in maintaining healthy communities. As prominent health risks to the community continue their shift from contagious diseases to chronic illnesses, public health departments are increasingly focused on conditions such as diabetes and obesity. At the same time, serious threats persist from traditional public health concerns, such as communicable disease outbreaks.Primary care providers, and particularly community health centers (CHCs), that provide care for low-income populations are on the front lines in treating and containing both communicable diseases and chronic illnesses that are more prevalent in these communities. Traditional models of primary care are also evolving, with increased focus on community-based approaches in response to changing financial incentives and formal recognition programs, such as the Patient-Centered Medical Home certification offered by the National Committee for Quality Assurance and the Joint Commission.1,2 Use of these models is facilitated by the parallel increase in adoption of EHRs.Federal incentive programs have been a proponent of EHR implementation and “meaningful use” of EHRs among primary care providers, with targeted funding to support their adoption among CHCs.3 The promotion of health information technology to improve the public’s health is 1 of 5 focus areas for meaningful use of EHRs. Finally, 1 of the 3-part aims of the Centers for Medicare and Medicaid Services (CMMS) is the improvement of population health—a goal that will only be met through improved coordination of primary care and public health.4,5In 2003, the potential for addressing community health needs with the aid of EHR data exchange initiated a partnership between The New York City Department of Health and Mental Hygiene (NYC DOHMH) and The Institute for Family Health. Together, these organizations have developed, tested, implemented, and monitored the use of an EHR in meeting public health and primary care goals. NYC DOHMH is one of the world’s largest public health agencies, operating programs in disease control, environmental health, epidemiology, health care access, health promotion and disease prevention, and mental hygiene. It also makes public health-enabled EHRs available to over 2500 primary care providers throughout New York City as part of its Primary Care Information Project (PCIP).The Institute for Family Health is a nonprofit organization that provides care to more than 80 000 patients in 26 federally qualified health center sites in New York City and New York State’s Mid-Hudson Valley. The Institute’s goal in establishing an EHR system was not only to enhance the quality of patient care in its own practices, but also to improve the health of the communities it serves. Recognizing that the 2 organizations had parallel missions to maintain healthy communities, the Institute and NYC DOHMH partnered in EHR data exchange initiatives to meet the shared goals of improving the surveillance and management of both communicable disease and chronic disease. Projects addressing these goals are described below.     

Educating Health Care Professionals in Advocacy for Childhood Obesity Prevention in Their Communities: Integrating Public Health and Primary Care in the Be Our Voice Project

Objectives. We assessed the perceived need for and the effectiveness of the Be Our Voice advocacy training. In this training, health care professionals learned public health strategies to advocate for environmental systems changes to prevent childhood obesity in their communities.Methods. We assessed 13 trainings across 8 pilot sites. We conducted 2 rounds of surveys with participants—pre-training (n = 287, 84% response rate) and immediately post-training (n = 254, 75% response rate)—and semi-structured interviews with participants after training (n = 25).Results. We uncovered essential and promising elements of the training. Primary care providers found the Be Our Voice training effective at building their comfort with and motivation for engaging in public health advocacy; they reported achieving learning objectives, and they had positive responses to the training overall and to specific sessions. They articulated the need for the training and plans for advocacy in their communities.Conclusions. The Be Our Voice training provides an opportunity to integrate primary care providers into public health, community-based advocacy. It may be a model for future educational offerings for health care professionals in graduate and postgraduate training and in practice.The effort to reverse the epidemic of childhood obesity in the United States provides a key opportunity to integrate public health and primary care by educating clinicians to be public health advocates in their communities. Obesity rates among the nation''s children have tripled in the past 30 years.1 As of 2008, over 30% of children aged 2 to 19 years had body mass indexes at or above the 85th percentile for their age.2Public health strategies for community-level prevention and environmental change hold particular promise for positively affecting the environments in which children live, learn, and play, and ultimately, for reversing the obesity epidemic.3,4 Integrating the clinical expertise of primary care providers with such public health approaches may further accelerate obesity prevention in communities. Through the approach of community-oriented primary care, there is longstanding precedent for efforts to bring together primary care and public health at the community level.5–8Health care professionals (HCPs) have daily exposure to the childhood obesity epidemic via the patients they treat, and they are trusted leaders in and resources for their communities.9 Their scientific and clinical knowledge of the epidemic coupled with this trusted community role positions HCPs to participate in community-based advocacy outside of their clinics.10 Expert committees and professional organizations have called on HCPs to collaborate with the public health community and to engage in community-based advocacy, and research has demonstrated that many clinicians are interested in advocacy.11–13 Tobacco control, often cited by those engaged in reversing the obesity epidemic, is the most visible of several public health advances that benefitted from the active engagement of HCPs.14 For example, HCPs have been important participants in public health campaigns on issues including promotion of child safety seats and bicycle helmets.15–17Despite this potential role for HCPs as advocates, substantial barriers hinder clinicians becoming engaged in public health advocacy. Many medical schools include advocacy training in their curricula, and certain medical specialties, including pediatrics, require advocacy training as a part of residency training.18,19 However, although some curricular programs are beginning to be tested, standard curricula do not yet exist to guide these requirements, and there is insufficient attention to advocacy in continuing medical education.20,21 Additional barriers include clinical service delivery often being the sole determinant of payment, the time required to be involved in advocacy outside the clinic, and limitations in most clinicians’ knowledge of how to connect to their communities in public health advocacy.4,10,22,23In response to this opportunity, the National Initiative for Children''s Healthcare Quality, in partnership with the American Academy of Pediatrics (AAP), the California Medical Association Foundation, and the Robert Wood Johnson Foundation Center to Prevent Childhood Obesity—the “National Partners”—created the Be Our Voice project with support from the Robert Wood Johnson Foundation. The project provides training and follow-up support to primary care providers to participate in community-based public health advocacy for childhood obesity prevention in their communities. This study examined the perceived need for this training and initial responses to it among HCPs in 8 pilot Be Our Voice communities.     

COVID‐19: The Time for Collaboration Between Long‐Term Services and Supports,Health Care Systems,and Public Health Is Now

Policy Points

• To address systemic problems amplified by COVID‐19, we need to restructure US long‐term services and supports (LTSS) as they relate to both the health care systems and public health systems. We present both near‐term and long‐term policy solutions.
• Seven near‐term policy recommendations include requiring the uniform public reporting of COVID‐19 cases in all LTSS settings; identifying and supporting unpaid caregivers; bolstering protections for the direct care workforce; increasing coordination between public health departments and LTSS agencies and providers; enhancing collaboration and communication across health, LTSS, and public health systems; further reducing barriers to telehealth in LTSS; and providing incentives to care for vulnerable populations.
• Long‐term reform should focus on comprehensive workforce development, comprehensive LTSS financing reform, and the creation of an age‐friendly public health system.

ContextThe heavy toll of COVID‐19 brings the failings of the long‐term services and supports (LTSS) system in the United States into sharp focus. Although these are not new problems, the pandemic has exacerbated and amplified their impact to a point that they are impossible to ignore. The primary blame for the high rates of COVID‐19 infections and deaths has been assigned to formal LTSS care settings, specifically nursing homes. Yet other systemic problems have been unearthed during this pandemic: the failure to coordinate the US public health system at the federal level and the effects of long‐term disinvestment and neglect of state‐ and local‐level public health programs. Together these failures have contributed to an inability to coordinate with the LTSS system and to act early to protect residents and staff in the LTSS care settings that are hotspots for infection, spread, and serious negative health outcomes.MethodsWe analyze several impacts of the COVID‐19 pandemic on the US LTSS system and policy arrangements. The economic toll on state budgets has been multifaceted, and the pandemic has had a direct impact on Medicaid, the primary funder of LTSS, which in turn has further exacerbated the states’ fiscal problems. Both the inequalities across race, ethnicity, and socioeconomic status as well as the increased burden on unpaid caregivers are clear. So too is the need to better integrate LTSS with the health, social care, and public health systems.FindingsWe propose seven near‐term actions that US policymakers could take: implementing a uniform public reporting of COVID‐19 cases in LTSS settings; identifying and supporting unpaid caregivers; bolstering support for the direct care workforce; increasing coordination between public health departments and LTSS agencies and providers; enhancing collaboration and communication across health, LTSS, and public health systems; further reducing the barriers to telehealth in LTSS; and providing incentives to care for our most vulnerable populations. Our analysis also demonstrates that our nation requires comprehensive reform to build the LTSS system we need through comprehensive workforce development, universal coverage through comprehensive financing reform, and the creation of an age‐friendly public health system.ConclusionsCOVID‐19 has exposed the many deficits of the US LTSS system and made clear the interdependence of LTSS with public health. Policymakers have an opportunity to address these failings through a substantive reform of the LTSS system and increased collaboration with public health agencies and leaders. The opportunity for reform is now.     

Economic Crisis,Restrictive Policies,and the Population’s Health and Health Care: The Greek Case

The global economic crisis has affected the Greek economy with unprecedented severity, making Greece an important test of the relationship between socioeconomic determinants and a population’s well-being.Suicide and homicide mortality rates among men increased by 22.7% and 27.6%, respectively, between 2007 and 2009, and mental disorders, substance abuse, and infectious disease morbidity showed deteriorating trends during 2010 and 2011. Utilization of public inpatient and primary care services rose by 6.2% and 21.9%, respectively, between 2010 and 2011, while the Ministry of Health’s total expenditures fell by 23.7% between 2009 and 2011.In a time of economic turmoil, rising health care needs and increasing demand for public services collide with austerity and privatization policies, exposing Greece’s population health to further risks.THE CURRENT GLOBAL ECOnomic crisis, manifested in 2007 with the collapse of the subprime mortgage market and the bankruptcy of several financial institutions in the United States, affected the Greek economy—viewed by some as the Eurozone’s weakened economic link—with unprecedented severity.Many commentators in the past and present have debated whether the ongoing international economic turmoil, the worst since the Great Depression, threatens the health of the population both in the United States and throughout the developed and less-developed world.1–5 The World Health Organization has added one more concern to this dialogue: whether spending restrictions in times of economic downturn (especially in countries that have required emergency assistance from the International Monetary Fund [IMF]) could impose further risks on the population’s health.6,7We present empirical evidence from Greece’s experience that clarifies the impact of restrictive policies during economic crisis and illustrates the implications for public health in other countries.     

End-of-Life Care Issues: A Personal,Economic, Public Policy,and Public Health Crisis

Advance directive documents are free, legal, and readily available, yet too few Americans have completed one. Initiating discussions about death is challenging, but progress in medical technology, which leads to increasingly complex medical care choices, makes this imperative.Advance directives help manage decision-making during medical crises and end-of-life care. They allow personalized care according to individual values and a likely reduction in end-of-life health care costs.We argue that advance directives should be part of the public health policy agenda and health reform.IS END-OF-LIFE CARE A MATTER of personal values, economics, public policy, or a looming public health crisis? Actually, it is all of these. But when we consider the population’s demographic shift to older adults, which is associated with chronic illness and multiple comorbidities, the enormous health care costs consumed in end-of-life care, and complex ethical issues, it is time for the public health community to put this issue squarely on its agenda. Increasing the rate of completion of advance directives is a key step, and specific policy strategies can be identified to accomplish this objective.Advance directives were created by federal and state law to ensure autonomy of patients who eventually become unable to make decisions for themselves.1,2 Advance directives are free, legal, and straightforward forms that can be completed in a few minutes. Typically, advance directives address several areas regarding end-of-life care when a person becomes unable to make medical decisions for himself or herself. First, a person defines the amount and kind of care he or she might receive under various medical circumstances. Second, a person designates a health care agent to make medical decisions when the person can no longer do so. Third, advance directives may also address other end-of-life care issues including organ donation, whole body donation to medical schools, funeral and burial arrangements, legacy recordings for posterity, and—in 3 states (Oregon, Washington, and Montana)—assisted dying.     

Public Health Department Accreditation Implementation: Transforming Public Health Department Performance

In response to a call for improved quality and consistency in public health departments, the Public Health Accreditation Board (PHAB) is leading a voluntary public health accreditation initiative in the United States.The public health department accreditation system will implement a comprehensive set of standards that set uniform performance expectations for health departments to provide the services necessary to keep communities healthy. Continuous quality improvement is a major component of PHAB accreditation, demonstrating a commitment to empower and encourage public health departments to continuously improve their performance.The accreditation process was tested in 30 health departments around the country in 2009 and 2010, and was launched on a national level in September 2011 at the National Press Club in Washington, DC.ACCREDITATION IS A WELL-established process for improving performance within organizations1 and takes place when a formal authority concludes that an organization meets predetermined standards.2 In the health care field, the Joint Commission and National Committee for Quality Assurance are long-standing, respected accreditation authorities recognized for establishing standards and advancing quality through accreditation of health care organizations.3,4 Initiatives undertaken in 4 states—North Carolina, Michigan, Missouri, and Illinois—have demonstrated the relevance and usefulness of similar accreditation systems in public health. 5–8 Important lessons have been learned from these programs about the need for and development of a national public health accreditation system. Nonetheless, despite state examples and the critical role of public health in the health of the nation, no national accreditation organization has been established to ensure public health department standards of performance, until now.Public health department accreditation has become one of the most important initiatives in public health today, representing the culmination of many years of collaboration and research. Leading this initiative is the Public Health Accreditation Board (PHAB), a nonprofit organization dedicated to advancing the continuous quality improvement of state, local, tribal, and territorial health departments through accreditation.9 The goal of the PHAB, set by the Robert Wood Johnson Foundation and the Center for Disease Control and Prevention, is to ensure that 60% of the US population is served by an accredited health department by 2015.10,11 Achievement of this goal is expected to promote and protect the health of the public by advancing the performance of state, tribal, territorial, and local public health departments.9,12We have provided an overview of the voluntary national accreditation program led by the PHAB, the current status of accreditation, and a roadmap for next steps that will be undertaken in the transformation of public health quality in the United States.     

Change in Health Insurance Coverage in Massachusetts and Other New England States by Perceived Health Status: Potential Impact of Health Reform

Objectives. We examined the impact of Massachusetts health reform and its public health component (enacted in 2006) on change in health insurance coverage by perceived health.Methods. We used 2003–2009 Behavioral Risk Factor Surveillance System data. We used a difference-in-differences framework to examine the experience in Massachusetts to predict the outcomes of national health care reform.Results. The proportion of adults aged 18 to 64 years with health insurance coverage increased more in Massachusetts than in other New England states (4.5%; 95% confidence interval [CI] = 3.5%, 5.6%). For those with higher perceived health care need (more recent mentally and physically unhealthy days and activity limitation days [ALDs]), the postreform proportion significantly exceeded prereform (P < .001). Groups with higher perceived health care need represented a disproportionate increase in health insurance coverage in Massachusetts compared with other New England states—from 4.3% (95% CI = 3.3%, 5.4%) for fewer than 14 ALDs to 9.0% (95% CI = 4.5%, 13.5%) for 14 or more ALDs.Conclusions. On the basis of the Massachusetts experience, full implementation of the Affordable Care Act may increase health insurance coverage especially among populations with higher perceived health care need.The sweeping health reform initiative in Massachusetts, An Act Providing Access to Affordable, Quality, Accountable Health Care (enacted April 12, 2006),1 provides a natural experiment with outcomes that may foreshadow those of the comprehensive national health reform President Obama signed into law 4 years later. The Patient Protection and Affordable Care Act (enacted March 23, 2010)2 and amendments in the Health Care and Education Reconciliation Act (enacted March 30, 2010),3 are collectively referred to as the Affordable Care Act (ACA).This landmark federal law includes provisions to strengthen the public health system, provide mandatory funding for prevention and wellness programs and activities, strengthen the Medicare program, implement insurance market reforms, bolster public health and primary care workforce, and improve the overall quality of the nation’s health system. The act focuses on expanding health insurance coverage and improving the health care delivery system beginning with incremental reforms in 2010 and following up with more substantial changes such as individual mandates, employer requirements, expansion of public programs, premium and cost-sharing subsidies to individuals, premium subsidies to employers, tax changes, and health insurance exchanges in 2014. Importantly, the law also prevents insurers from denying health insurance coverage or charging higher premiums on the basis of health status.4,5 The Congressional Budget Office estimates that, when fully implemented in 2019, ACA will provide coverage to an additional 32 million Americans leaving about 23 million nonelderly people uninsured.6Systematic reviews of the literature on the impact of health insurance on health care utilization and health outcomes provide some convincing and some nuanced conclusions. These reviews consistently report evidence of increased utilization of physician and preventive services, improvements in the health of vulnerable populations, and lower mortality, conditional on injury and disease; however, how health insurance affects health outcomes for nonelderly adults remains unclear.7,8From a public health perspective, monitoring implementation of ACA at federal, state, and local levels will be important because this act will change health insurance coverage and access to care, and uptake of care, including preventive services and needed treatment; may alter health care finance and payment structures and care delivery systems as well as health expenditures; and may modify individual and population outcomes of care and health status. Studying the effects of health insurance would ideally rely on experimental evidence7 where health insurance was randomly assigned like the RAND Health Insurance Experiment and the Oregon Medicaid Lottery.9,10 In the absence of randomized experiments, owing to ethical and practical considerations, the need for conducting some social experiments or other approaches to infer causal conclusions from observational data are essential.7,11Fortunately, a natural experiment of near universal health insurance coverage combined with a targeted public health intervention has been unfolding in Massachusetts for more than 3 years and has been the subject of many studies. Researchers have studied various aspects of the impact of Massachusetts health reform, after 1 year,12 over the short term, comparing 18 months before and 18 months after the reform,13 on young adults and children,14,15 and even the effects of the recession.16 This evolving new body of research leaves a gap in our understanding of the impact of health reform by perceived health care need. We examined the impact of the Massachusetts health reform and its public health component on change in health insurance coverage by perceived health. We examined the impact of the natural experiment in Massachusetts as a model to predict likely outcomes of implementing ACA. Because Medicare already covers most of those aged 65 years and older we compared the effectiveness of mandatory versus optional health insurance among only the nonelderly adult population (aged 18–64 years) residing in Massachusetts and other New England states (Connecticut, Maine, New Hampshire, Rhode Island, and Vermont).To do this, we compared data between the 3 years (2003–2005) before and the 3 years (2007–2009) after Massachusetts enacted the health reform law and between Massachusetts and other New England states that had no similar health reform laws. Massachusetts and other New England states had similar sociodemographic population characteristics and macroeconomic profiles (e.g., gross domestic product, unemployment rates) over this time period, including a similar impact of 2 years of recession (2007–2009).17,18 This allows not only “before-versus-after” but also “with-versus-without” analyses, a strategy employed by other researchers to explicate the impact of health reform laws and policy as a control for other elements.16,19We used the Behavioral Risk Factor Surveillance System (BRFSS), the largest and longest-running state-representative, population-based telephone survey that has asked questions about health insurance coverage, health-promoting and health-compromising behaviors, and doctor-diagnosed chronic conditions. Existing federal government and state-sponsored surveys generate different estimates of uninsurance possibly explained by differences in survey design including coverage, reference period, mode, and questionnaire design (wording and placement of questions).20–22 First, we established the quality and the consistency of BRFSS health insurance coverage estimates by comparing these estimates for selected demographic and socioeconomic characteristics with other federal surveys that gather data on health insurance—the American Community Survey (ACS), the Annual Social and Economic Supplement to the Current Population Survey (CPS ASEC), and the National Health Interview Survey (NHIS). The US Census Bureau added a question about health insurance to the 2008 ACS leading to the release of the first set of estimates in September 2009.23 The CPS ASEC is the most widely cited source for health insurance statistics. It is annual, timely, relatively large, and has a state-based design. The NHIS is a continuing nationwide survey conducted by the National Center for Health Statistics.23We hypothesized a greater increase in the proportion of nonelderly adults with health insurance coverage in Massachusetts than in other New England states. We further hypothesized that nonelderly adults with greater perceived health care needs would be more likely to obtain health insurance coverage. Groups with greater perceived health care need would show a larger increase in health insurance coverage from prereform to postreform and in Massachusetts compared with other New England states.     

The Common Ground Preparedness Framework: A Comprehensive Description of Public Health Emergency Preparedness

Currently, public health emergency preparedness (PHEP) is not well defined. Discussions about public health preparedness often make little progress, for lack of a shared understanding of the topic. We present a concise yet comprehensive framework describing PHEP activities. The framework, which was refined for 3 years by state and local health departments, uses terms easily recognized by the public health workforce within an information flow consistent with the National Incident Management System. To assess the framework''s completeness, strengths, and weaknesses, we compare it to 4 other frameworks: the RAND Corporation''s PREPARE Pandemic Influenza Quality Improvement Toolkit, the National Response Framework''s Public Health and Medical Services Functional Areas, the National Health Security Strategy Capabilities List, and the Centers for Disease Control and Prevention''s PHEP Capabilities.“All models are wrong, some models are useful.”—George Box1Public health emergency preparedness (PHEP) has been defined as “the capability of the public health and health care systems, communities, and individuals, to prevent, protect against, quickly respond to, and recover from health emergencies, particularly those whose scale, timing, or unpredictability threatens to overwhelm routine capabilities.”2^(p24) However, compared with more traditional public health activities such as food safety inspections, outbreak investigations, community health assessments, immunization clinics, and environmental monitoring, PHEP activities are not clearly defined.2–4We present a framework describing what public health agencies do to prepare for, respond to, and recover from public health emergencies. The framework was developed through a collaboration of state and local health departments, brought together by the Public Health Informatics Institute with funding from the Robert Wood Johnson Foundation to define business processes related to PHEP.The Common Ground Preparedness Framework (CGPF) adds to other PHEP frameworks by more explicitly capturing how public health agencies prepare for and respond to public health emergencies. Combining comprehensiveness with specificity, it is especially useful in describing PHEP to both public health agencies and their partners in emergency response. It also provides a framework for incident action plans and after-action assessments, resource distribution, information systems, and training.     

The Current and Projected Taxpayer Shares of US Health Costs

Objectives. We estimated taxpayers’ current and projected share of US health expenditures, including government payments for public employees’ health benefits as well as tax subsidies to private health spending.Methods. We tabulated official Centers for Medicare and Medicaid Services figures on direct government spending for health programs and public employees’ health benefits for 2013, and projected figures through 2024. We calculated the value of tax subsidies for private spending from official federal budget documents and figures for state and local tax collections.Results. Tax-funded health expenditures totaled $1.877 trillion in 2013 and are projected to increase to $3.642 trillion in 2024. Government’s share of overall health spending was 64.3% of national health expenditures in 2013 and will rise to 67.1% in 2024. Government health expenditures in the United States account for a larger share of gross domestic product (11.2% in 2013) than do total health expenditures in any other nation.Conclusions. Contrary to public perceptions and official Centers for Medicare and Medicaid Services estimates, government funds most health care in the United States. Appreciation of government’s predominant role in health funding might encourage more appropriate and equitable targeting of health expenditures.The United States has the world’s highest per capita health care costs—about double those of other wealthy nations.1 According to both official figures and public perception, most health care funding in the United States comes from private payers. For instance, the Centers for Medicare and Medicaid Services (CMS) estimates that federal, state, and local governments accounted for 43% of health expenditures in 2013.2These official figures reflect an accounting framework based on who wrote the final check as money flowed from households or employers to health care providers, and exclude many indirect government health expenditures. Thus, when government pays for veterans’ care, CMS classifies it as a public expenditure because government writes the checks that fund the Veterans Health Administration. But CMS classifies government-paid health benefits for senators or Federal Bureau of Investigation agents as “private” expenditures because a private insurer pays the claims. Moreover, the tax subsidies that fund a significant share of private health expenditures (e.g., private-employer spending) are not counted by CMS as government health spending, although the Office of Management and Budget (OMB) tabulates these subsidies as “tax expenditures” in official budget documents.3In a previous study, we estimated that the public share of US health spending—after inclusion of these tax subsidies and government payments for public employees’ health benefits—amounted to 59.8% of the total in 1999, nearly double the 1965 figure.4 The current study provides detailed estimates of direct and indirect government health spending in 2013, as well as projected figures through 2024.     

Integration of Primary Health Care and Public Health During a Public Health Emergency

We have provided a detailed evaluation of how collaboration between an Ontario public health unit and its primary care providers facilitated an optimal response to the 2009 H1N1 influenza pandemic.Family health teams (integrated, interdisciplinary teams that provide a range of care options) provided flu assessment centers, with public health as a partner providing infection control advice, funding, coordination, antiviral medication, clinical care guidelines, supplemental nurse staffing, and arrangement of communication strategies with the public.The family health team structure offers a new capacity for timely, coordinated, and comprehensive response to public health emergencies, in partnership with public health, and provides a promising new direction for healthcare organization.The H1N1 pandemic of 2009 killed nearly 13 000 people worldwide by year’s end.1 More specifically, H1N1 had a substantial impact on Canada’s health care system, resulting in 8596 hospitalizations, 1446 intensive care unit admissions, and 426 deaths.2 In just nine months in the province of Ontario, emergency departments (EDs) received roughly 140 000 more patients with flu-like symptoms than they had in previous years, and the national cost of responding to H1N1 has been estimated at more than $2 billion.3 In southeastern Ontario’s Kingston, Frontenac, and Lennox & Addington (KFLA) Health Unit, the new primary care provider (PCP) structure facilitated a partnership between PCPs and public health and an optimal response to the 2009 pandemic. The improved PCP structure allowed a timely and comprehensive response to pandemic H1N1 by providing enhanced coordination, communication, and collaboration among PCPs and with public health and offered a new capacity for ongoing partnerships between PCPs and public health.     

Training Primary Care Physicians for Local Health Authority Duties in Texas

Only one fourth of Texas counties have a local health authority (LHA) or health district. Primary care physicians in the remaining counties could be trained in public health basics by providing an online LHA training course and courses at annual meetings of the Texas Medical Association and the Texas Academy of Family Physicians.The Texas Department of State Health Services should develop a web portal for LHAs. The Texas Association of Local Health Officials should also provide automatic limited membership for LHAs.These initiatives would provide public health training to primary care physicians and would greatly improve availability of public health services for the citizens of Texas.The US Department of Health and Human Services recently identified priority drivers of public health quality and outcomes. One of these priority drivers is “workforce and education,” developing and sustaining a competent public health workforce by “ensuring that educational and skills content are appropriately aligned with core and discipline-specific competencies.”1^(p4) As members of the public health workforce, local health authorities (LHAs) have the responsibility to connect the health of individuals to public health services in the communities which they serve. The role of the LHA is essential to assuring a vision of healthy people in healthy communities. This analytic essay describes a collaborative approach to facilitate clinician education and lifelong learning, contributing to the national goal of population health improvement.     

Local Public Health Systems and the Incidence of Sexually Transmitted Diseases

Objectives. We examined the associations of local public health system organization and local health department resources with county-level sexually transmitted disease (STD) incidence rates in large US health jurisdictions.Methods. We linked annual county STD incidence data (2005–2008) to local health department director responses (n = 211) to the 2006 wave of the National Longitudinal Study of Local Public Health Systems, the 2005 national Local Health Department Profile Survey, and the Area Resource File. We used nested mixed effects regression models to assess the relative contribution of local public health system organization, local health department financial and resource factors, and sociodemographic factors known to be associated with STD incidence to county-level (n = 307) STD incidence.Results. Jurisdictions with local governing boards had significantly lower county-level STD incidence. Local public health systems with comprehensive services where local health departments shoulder much of the effort had higher county-level STD rates than did conventional systems.Conclusions. More integration of system partners in local public health system activities, through governance and interorganizational arrangements, may reduce the incidence and burden of STDs.US annual sexually transmitted disease (STD) incidence rates have not declined despite the identification of effective surveillance and prevention methods.1–5 For example, after decreasing annually since 1999, gonorrhea infection rates among adolescents increased 2% from 2004 to 2005, from 421.9 to 431.8 per 100 000, and then increased 6% again from 2005 to 2006, from 431.8 to 458.8 per 100 000.6,7 Untreated STDs can have serious long-term health effects, such as cervical cancer, infertility, and pregnancy complications.8 STDs are among the largest Black–White racial disparities in health,9 which are heavily influenced by social determinants (i.e., area-level sociodemographic factors).9–12It is a widely accepted view that local health departments and their system partners play a critical role in controlling the spread of STDs.13–15 Local health departments differ dramatically in size, organizational structure, and available resources, and these factors can influence the reach and effectiveness of local STD prevention strategies. Previous studies indicate that larger local health departments, better resourced local health departments (as measured by expenditures per capita), and jurisdictions with local boards of health with policymaking authority more consistently provide a diverse set of essential public health functions,16–19 including diagnosing and preventing health problems and informing and educating the public about health issues. Moreover, recent evidence indicates that increases in STD prevention funding are associated with reductions in gonorrhea20 and syphilis21 incidence rates. This suggests that resources available to local health departments and their system partners can affect the “reach” of STD prevention programs.The contribution of community partner organizations to performing essential public health functions18 may also influence the reach and effectiveness of STD prevention and treatment programs. For example, low integration of local health departments with their local system partners, including physician organizations, community health centers, and faith-based organizations, can impinge on the effectiveness of local STD prevention and treatment efforts.15 Given that rescreening previously infected individuals is increasingly viewed as central to controlling the spread of STDs,22 local health departments that have low integration with their health care delivery system partners might face more difficulties curtailing the spread of STDs. It may be difficult for local health departments that have limited integration with system partners to communicate surveillance data and to generate action to combat emerging health epidemics.Little research, however, has assessed organizational and market determinants of local public health system effectiveness using population health indicators.17–19 Although several studies have assessed the relationship of county-level sociodemographic factors and STD rates,23,24 to our knowledge, no study has ever assessed the relationship of local public health system organization and STD incidence rates. Consequently, the extent to which the scope of local health department services and their integration with their local health system partners is associated with STD incidence rates remains unclear. Using responses to the National Association of County and City Health Officials (NACCHO) 2005 National Profile of Local Health Departments in the United States (NACCHO Profile) and county-level data from the Area Resource File, we examined the extent to which local health department financing per capita, the existence of a local governing board of health, and integration among key system partners are associated with county-level incidence rates of gonorrhea and chlamydia.Consistent with previous research examining public health spending and medical care expenditures,25 we hypothesized that local health departments with greater total expenditures per capita have lower STD incidence rates when controlling for county-level sociodemographic and other local health department characteristics. Local boards of health are increasingly considered central to improving community-based linkages and setting priorities for jurisdictions. Accordingly, we hypothesized that county-level STD rates would be lower in jurisdictions where local boards of health have governance responsibility than in those having no local board of health. The integration of local health departments with local public health system partners can influence the dissemination of preventive health care information and epidemiologic data to target interventions. We hypothesized that local health departments with a higher integration with system partners, as measured by the recent typology of local public health systems,26,27 have lower STD incidence rates, controlling for other factors. Finally, we examined the role of social determinants of STD incidence relative to measurable local public health system factors.