By John Middaugh, MD
For the past eight years, the United States has focused on its healthcare system in the aftermath of the passage of the Affordable Care Act (ACA). Its complexity and cost have guaranteed controversy. With a new Republican president and Congress committed to repealing the ACA, no clear remedy has emerged.
In 2015 US health expenditures were estimated to be about $3 trillion a year, accounting for 18% of the US economy1. In spite of the success of the ACA in extending health coverage to more than 20 million previously uninsured people, millions remain uninsured without access to health care. And, in spite of the huge expenditures, the performance of the health care system is mediocre.
A serious unintended consequence of the ACA has been the neglect of the public health system in the US. During the past eight years, understanding and support of public health agencies have drastically declined, especially at the state and local levels. Since 2008 more than 40,000 public health jobs have been lost, essential program services eliminated, and capacity reduced.2 Many public health agencies were forced to divert staff and limited resources to public health preparedness, further compromising core public health programs.
Proponents of the ACA incorrectly believed that many public health programs and services would not be needed because the health care system would provide care to those who were newly covered by the ACA. This idea was perpetuated by applying new terms to market and advocate for passage of the ACA. Population health and individual clinical care for preventive health services became synonymous with the public health system. This confusion resulted in diverting millions of dollars from State and local public health agencies.
Public health protects the community. Public health authority is derived from the US Constitution under powers reserved to the States. Because public health services are essential to protect the community, public health agencies rely on local and state funding for support. While public health agencies provide some clinical health care services to individuals, public health agencies exist to protect communities by providing complex and sophisticated services that individuals, acting alone, cannot achieve for themselves. Public health agencies are service agencies. While they may provide some clinical care, may conduct limited research, and may provide some training, they are the source of community protection.
Public health is not the same as healthcare services, and the ACA does not provide public health services. For example, individual health care providers respond to infectious disease threats and may require considerable expertise to treat the patient. If a case of meningococcal meningitis or botulism is diagnosed, the health care provider is focused on the care of the patient. The public health agency is responsible for investigating the source of the infection, who was exposed, and providing prophylactic medications or confiscating the implicated food. In these circumstances, the public health agency has no one to bill, and there is no one else to conduct the investigation.
One of the most basic, fundamental activities of public health agencies is to conduct public health surveillance. Public health agencies are founded on authority based in the US Constitution and local and state public health laws to enforce public health measures enacted as local and state statutes, regulations, and administrative procedures. Some of these essential protections are collecting population data; monitoring births, deaths, marriages, and divorces; disease reporting; isolation and quarantine; regulating the safety of drinking water, waste disposal, clean air, food and drug safety; and control of zoonotic diseases and vector control. Public health also monitors the health of the population and identifies threats and risk factors. It designs programs to reduce or eliminate these threats or risk factors and monitors the effectiveness of control measures.
Maintaining public health systems requires highly skilled professionals drawing from many academic disciplines and specialties. Excellence and capacity cannot be obtained overnight. Sustained funding and political and community support are essential to achieving success. Public health outcomes can be measured. When public health programs are effective, diseases and injuries and deaths and disabilities are prevented. When disease outbreaks are prevented, there is no media coverage. So, public health programs can become invisible and often are taken for granted.
Unfortunately, it often takes a breakdown in the system or a new disease outbreak to provide examples of the essential value of the public health system. For example, the recent exposure of residents of Flint, Michigan to lead in the cities drinking water was the result of severe budget cuts of the public health agencies.
Threats to public health are constantly present and new threats emerging. For example, the nation is grappling with a massive epidemic of prescription drug overdose deaths; life expectancy of the new generation is predicted to fall for the first time due to the epidemic of obesity and diabetes; and the recent outbreak of Ebola virus in West Africa and Zika Virus in Brazil and its rapid spread. Only a viable and valued public health system can protect communities.
Comparing local and state public health agencies in the US is very difficult. There are many different models and structures in the country. The United Health Foundation and Trust for America’s Health have collected information on public health funding and public health measures annually for decades, as has the National Association of State and Territorial Health Officers (ASTHO) and National Association of County and City Health Officers (NACCHO).
Health in Arizona is seriously neglected, underfunded, and under-staffed. The median funding for public health from state and federal sources in the US is $85.52 per person. In comparison, Arizona funding if $38.50 per person, ranking 49 of 51. Arizona provides $8.40 per person in state funding for public health compared to the US median of $31.06 per person. Among states in the Southwest, only Nevada provides less funding than Arizona.
Comparing public health population, number of visitors, and funding between the Southern Nevada Health District, Nevada, and Seattle-King County, Washington, and Maricopa County Health Department, Arizona, the Maricopa County Health Department has more than double the population and the fewest full-time employees (FTEs). Maricopa County funded its public health agency in FY 2016 at $11,467,877 in general revenue, or only $2.75 per person, among the lowest in the US.
Population projections estimate that Arizona will grow by 588,536 people by 2020. Without an increase in public health funding and staff, the Arizona Department of Public Health and the Maricopa County Health Department will fall further behind. The future also will bring new public health challenges and threats. Some of the most certain will be related to Bioterrorism, Climate Change, Emerging Infections, Zoonotic Diseases, Antibiotic Resistance, Global Travel and Immigration, Global Food Supply, and Population Growth.
Arizona trails most of the States in many public health outcome measures. This is of great concern, because these summary measures hide wide disparities among different racial and ethnic groups, among those earning less income, and among those who have less education. Arizona and Maricopa County trail many other states and counties in childhood immunization rates (19-35 months old). Of greater concern is that many charter schools do not enforce childhood vaccination requirements, and many have less than 40-50 % of their children fully vaccinated.
“Never Events” are well described in hospital medical care. For example, the amputation of the wrong limb is a “Never Event.” Removal of the wrong kidney is a “Never Event.” In public health, “Never events” should include congenital syphilis. Yet, there have been between 12 – 24 cases of congenital syphilis in Arizona each year for the past ten years. There has been a resurgence of syphilis and HIV infections, and the rates of gonorrhea and chlamydia have been climbing. Arizona has been heavily impacted by the prescription drug epidemic of overdose fatalities.
Summary data on public health outcomes document that the public health status in Maricopa County and Arizona is worse than a majority of other states. These summary statistics do not reflect the wide disparities and far worse health status among certain racial and ethnic groups, those who are less well off economically, and those who are less educated. With the population expected to grow by almost 600,000 people by 2020, the public health system will not be able to maintain even existing levels of public health.
No matter what solutions to the ACA are implemented, health care services will not include public health support nor will these public health disparities lessen. Public health agencies rely on local and state tax revenues to support the public health programs that protect all people in the community. In 2016 the Arizona Medical Association and Maricopa County Medical Society passed resolutions calling for increased support for public health in Arizona. Now is the time to strengthen public health in Maricopa County and Arizona and protect the future.
McGinnis JM, Diaz A, and Halfon N. Systems strategies for health throughout the life course. 2016; 316: 1639-1640.
National Association of County and City Health Officials. Local Health Department Job Losses and Program Cuts: Findings from the 2013 Profile Study. July 2013. naccho.org/lhdbudget.