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To furnish an insight into organized public health activities in the United States.
Since the development of organized public health activities over the past two hundred years, the basis of such activities has remained essentially unaltered. The role of public health continues to focus on ways in which society can organize effective institutions that protect against disease and advance the health of the population. A major problem today lies in the fact that the structures erected for control of classical communicable and noninfectious diseases are ineffective relative to health care financing, environmental protection, and other aspects of public health and safety.
The organization of health and its administration are molded by the philosophy and goals of society. The legal basis for its operation and structure originates from the U.S. Constitution. The roles and responsibilities of government are established through the organization of 3 branches of federal government. The Congress has the power to legislate and appropriate tax monies for the support of government. The Executive Branch has the administrative responsibility for carrying out the intent of the Constitution, its amendments, national legislation, and executive guidelines. The Judiciary interprets the Constitution and national laws. These branches of government also exist at the state and local levels.
Historically, public health law originated from measures used to prevent or control communicable diseases. In the United States, each community is protected by an official governmental health agency, a part of the administrative branch of government.
There is distinguishable public health law. Also, there is an interrelationship of law and public health administration. Public health law is an expression of the application of general legal principles to the practice of public health and human safety.
In order to translate law into action, it is often necessary to impose rules, regulations, policies, and guidelines. These measures are concerned with the detailed methodology and/or processes of implementation. Health agencies have quasi-legislative and judicial authority in regulating health affairs. It is important to note that the administration of public health must always be contained within the context of legislative authority granting these powers.
Philosophically, the administration of health affairs by government has as it goal the greater good of society. Occasionally, the administration of health matters may infringe upon individual freedoms and property rights of citizens. One must be constantly aware of paternalism and placing an undue burden on society to justify governmental intervention. The constitutional guarantees of due process and equal protection are important considerations in reaching these goals.
State Health Departments (SHD). The state has the inherent authority to protect the health and welfare of its citizens. The 50 states and several territories act as autonomous bodies of inherent or plenary power. The authority to provide for the public health and welfare is defined by statute enacted by state legislature. The basis for those statues is constitutionally protected and is an attribute of a sovereign government. While implicit in this authority is the responsibility for the public health agency to protect the public from a dangerous disease and to take such steps as may be necessary (a police power function); however, the explicit exercise of police power function is rarely carried out or mentioned.
A review of the Association of State and Territorial Health Officials lists 50 state health agencies, the District of Columbia and 8 territories representing the network for health reporting activities. Some of the activities of the state health agencies are: maternal and child health, mental and dental health, environmental health, administration and communicable disease control. In most states, medicare is not a part of the state health agency. Non-traditional health programs include: primary care centers, health insurance programs for the aged and indigent, community mental health and comprehensive health planning.
These governmental units are difficult to define since they keep changing and are different from state to state. A local health department is defined as an official governmental public health agency which in whole or in part is responsible to a state governmental entity; has a staff of 1 or more full-time professional employees; delivers public services; serves a definable geographic area and has an identifiable budget. The following are examples of local structure:
In the early 1960's, federal influences were exerted by the Office of Economic Opportunity and the Department of Health, Education and Welfare (now Department of Health and Human Services) to promote a community health service concept and making the local health department a part of the health delivery system.
The following are examples of the organizational structure and their operational authority:
Historically, the United States began with a commitment to a system of political economy based on free enterprise. The establishment of public health agencies at the federal level came from the need of the United States to be prepared nationally and internationally for any eventuality. While the original constitution remains the same, the intent, interpretation and application have changed.
The concern for increased trade contracts lead to prepaid medical care
for seamen and quarantine powers at seaports to control epidemics and the establishment of a system of charity hospitals later to become public hospitals. The Maternal and Infancy Act of 1921 to provide grants-in-aid to states and local communities, services for cripple children and child welfare services for predominately rural areas, including protection and care of the homeless and neglected.
Various levels of government must assume the function of providing for the existence of an appropriate organization, adequate personnel, clinical and laboratory facilities, training and financial support. With the passing of each decade, public health programs have become more centralized with relations to power and control from local to state to federal.
The cabinet-level agency responsible for public health is the Department of Health and Human Services (DHHS). The following generalizes the DHHS organizational plan:
Historically, in the United States, the concept of comprehensive health organization and service was not a serious concern until the mid 1900's. Prior to that time, public health services were essentially independent and under the control of the state health authority.
The following highlights some of the major legislative initiatives of the federal government:
3.7.1 Hospital Survey and Construction Act of 1946
This Act is commonly referred to as the Hill-Burton Act. The initial purpose for this legislation was to provide states with matching funds to support facilities planning and the construction of non profit hospitals in rural and economically depressed areas.
3.7.2 Amendments to the Social Security Act (1964)
These amendments were enacted to meet approximately 75% of the costs of comprehensive health services for children and youth living in areas with a concentration of low-income families. During that same year, Medicaid, a federal-state program of medical care for the poor was authorized. It became evident that any comprehensive system of medical care requires
- (i) medical care financing and
- (ii) the availability of clinic resources.
In 1965, a categorical system called Medicare, was initiated to serve the medical care needs of citizens 65 years or older and to the disabled.
3.7.3 Partnership of Health Act of 1966
This Act is commonly referred to as the Comprehensive Health Planning Act. The Act was based on the concept that a regional approach to health planning and organization was a model of efficiency. These regional units were established without mandatory involvement of the state and local health agency. The term community health service system was a substitute for the Public Health Service in order to avoid confusion and to emphasize community ownership and management. The system was to operate under nationally established goals and on a nationally funded system but locally governed. The community health service was under obligation to deliver comprehensive health care by official health agencies or by direct arrangement with other agencies.
3.7.4 National Health Planning and Resources Development Act, 1974
The purpose of this Act was to improve the quality of health care services, augment comprehensive delivery systems, cost containment and focus on planning for health needs. State and local health agencies were authorized to conduct long range health planning activities and Certificate of Need Programs. Certificate of Need Programs were to place controls in the expansion and use of new technology based on community need rather than consumer demand. The Act was also initiated to foster the development of Health Maintenance Organizations (HMOs) as competitive alternatives to the traditional fee for service.
3.7.5 The Omnibus Budget Reconciliation Act of 1981
The purpose of this Act was to usher in a new pattern of intergovernmental relations in public health. Under this legislation, planning, implementation and administration were transferred from federal to state control. The block grant concept was adopted in which many categorical programs were consolidated into preventive health, health services, primary care and maternal and child health with 25% less funding.
3.7.6 The Tax Equity and Fiscal Responsibility Act of 1982
This Act effected major changes in Medicare and Medicaid financing. Shifting responsibility for costs from federal to state government. This new system represented significant change in the way medicare pays hospitals by a replacement of a cost plus system to a system with prospective payments based on regionalized diagnosis related groups.
3.7.7 Balanced Budget and Emergency Deficit Control Act of 1985
This Act, referred to as the Gramm-Rudman-Hollings Bill, is designed to
gradually eliminate the deficit. For all practical purposes, cuts are to be split evenly between domestic and defense programs. Medicare cuts (aside from other laboratory payment cuts) are limited to 1% in FY86 and 2% thereafter. Medicaid is exempt. Gramm-Rudman-Hollings legislation calls for a balanced federal budget.
3.7.8 Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986
This Act establishes limits that Medicare will pay for laboratory tests. It also creates a method for compensating children who are injured by vaccines, authorizes a state mental health service program, extends the Health Maintenance Organization Act, and repeals the 1974 Health Planning Act.
3.7.9 Additional Medicare and Medicaid Provisions
Provisions have been implemented in the latter 1980’s by revisions in Titles 18 and 19 of the Federal Social Security Act. Further changes are expected in the 1990’s, relative to health coverage and expenses thereof.
DeFriese, G. H. et al., Program
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Manual, Second edition, American Public Health
Association, 1990. Hobson, W., Theory and Practice
of Public Health, Fifth edition, Oxford Press,
1979. Last, J. M. and Wallace, R. B.,
Maxcy-Rosenau-Last Public Health and Preventive Medicine,
13th edition, Appleton and Lange, 1992. Pickett, G. and Hanlon, J. J.,
Public Health Administration and Practice, Times
Mirror/Mosby College Publishing, 1990.
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