Issue Report
ISSUE REPORT
OCTOBER 2008
PREVENTING EPIDEMICS.
PROTECTING PEOPLE.
TRUST FOR AMERICA’S HEALTH IS A NON-PROFIT, NON-PARTISAN ORGANIZATION DEDICATED TO SAVING LIVES AND
MAKING DISEASE PREVENTION A NATIONAL PRIORITY.
This project is supported by a grant from the Robert Wood Johnson Foundation. The opinions expressed are those of the
authors and do not necessarily reflect the views of the Foundations.
TFAH BOARD OF DIRECTORS
REPORT AUTHORS
Lowell Weicker, Jr.
Jeffrey Levi, PhD.
President
Executive Director
Former 3-term U.S. Senator and
Trust for America’s Health and
Governor of Connecticut
Associate Professor in the Department of Health Policy
The George Washington University School of
Cynthia M. Harris, PhD, DABT
Public Health and Health Services
Vice President
Director and Associate Professor, Institute of
Sherry Kaiman
Public Health, Florida A & M University
Director of Policy Development
Trust for America’s Health
Margaret A. Hamburg, MD
Secretary
Chrissie Juliano, MPP
Senior Scientist, Nuclear Threat Initiative (NTI)
Policy Development Manager
Trust for America’s Health
Patricia Baumann, MS, JD
Treasurer
Laura M. Segal, MA
President and CEO, Bauman Foundation
Director of Public Affairs
Trust for America’s Health
Gail Christopher, DN
Vice President for Health
WK Kellogg Foundation
CONTRIBUTORS
John W. Everets
Daniella Gratale, MA
Government Relations Manager
David Fleming, MD
Trust for America’s Health
Director of Public Health
Seattle King County, Washington
Michael R. Taylor, JD
Research Professor
Arthur Garson, Jr., MD, MPH
George Washington School of Public Health
Executive Vice President and Provost and the Robert
And Health Services
C. Taylor Professor of Health Science and Public Policy
University of Virginia
Lynora Williams, MW
Consultant and Principal
Robert T. Harris, MD
Lyric Editorial Services
Former Chief Medical Officer and
Senior Vice President for Healthcare
BlueCross BlueShield of North Carolina
Alonzo Plough, MA, MPH, PhD
Vice President of Program, Planning and Evaluation
The California Endowment
Theodore Spencer
Project Manager
Natural Resources Defense Council
SECTION
Section 1 1
I N T R O D U C T I O N
SECTION
1
Blueprint for a
1
S E C T I O N
Healthier America:
MODERNIZING THE FEDERAL PUBLIC
HEALTH SYSTEM TO FOCUS ON
PREVENTION AND PREPAREDNESS
America is facing a health crisis. Even though America spends more
than $2 trillion annually on health care -- more than any other nation
in the world -- tens of millions of Americans suffer every day from preventable
diseases like type 2 diabetes, heart disease, and some forms of cancer that rob
them of their health and quality of life.1
In addition, major vulnerabilities
remain in our preparedness to respond to health emergencies, including
bioterrorism, natural disasters, and emerging infectious diseases.
The current public health system is broken.
ministration, and Congress with expert rec-
It is chronically underfunded and outdated.
ommendations to revitalize the nation’s abil-
Modernizing public health is urgently
ity to protect the health of all Americans.
needed to protect and improve the health of
Trust for America’s Health (TFAH) under-
Americans. Prevention, preparedness, and
took a year-long consensus-building process,
public health are vital to the wellbeing of
consulting more than 150 leading health ex-
families, communities, workplace productiv-
perts and organizations to assemble recom-
ity, U.S. competitiveness, and national secu-
mendations for effective ways to modernize
rity. The U.S. is falling behind as Americans
the federal public health system to meet the
become more unhealthy and less protected,
range of health challenges we face. TFAH
and health care costs skyrocket.
expresses its gratitude to everyone who was a
This Blueprint for a Healthier America is a fed-
part of this process.
eral policy guide for the next President, Ad-
1
The Blueprint contains:
I A vision statement signed by more than
Public Opinion Strategies for TFAH, in-
140 leading health organizations that out-
cluding reducing health care costs
lines principles to make disease and injury
through improved disease prevention, the
prevention a cornerstone of America’s
obesity epidemic, food safety, and pre-
health policies.
paredness for health emergencies. TFAH
has also focused attention on infant
I Recommendations to improve the infra-
health, which is a leading indicator for
structure of America’s public health sys-
how healthy a nation is, and addressing
tem - - funding, structure of agencies,
“social determinants” of health, which
accountability systems, workforce recruit-
looks at why some communities are health-
ment and retention, and integrating pub-
ier than others and ways to ensure all
lic health with health care - - which are all
Americans have the opportunity to be as
needed to support the foundation of all
healthy as they can be.
public health programs and services.
I An Agenda for Modernizing Public Health
I Recommendations from TFAH’s ongoing
paper that defines the need and scope for
initiatives and projects. TFAH issues a se-
a policy agenda to modernize public
ries of policy reports each year to bring
health. This paper is the result of a series
special attention to some of the nation’s
of consensus meetings with more than 35
most serious public health problems. A
experts and national organizations.
number of these issues reflect some of the
top health concerns Americans have based
The Blueprint for a Healthier America is supported
on public opinion research conducted by
by a grant from the Robert Wood Johnson
Greenberg Rosner Quinlan Research and
Foundation.
2
BLUEPRINT FOR A HEALTHIER AMERICA
TABLE OF CONTENTS
Section 1: Introduction
F. Medicare: Improving Prevention to Help
Contain Costs and Improve Health.
A. Our Vision for a Healthier America.
Recommendations for improving prevention
More than 140 leading health organizations
services offered by Medicare and ensuring
have signed on to a vision statement outlin-
Americans are healthier when they reach
ing the need to make disease and injury pre-
Medicare age.
vention the centerpiece of our national
strategy for improving the nation’s health.
G. Behavioral Health: A Necessary Com-
ponent of a Healthier America.
Section 2: Infrastructure
Recommendations for ensuring behavioral
Recommendations
health concerns are integrated into all public
A. Funding Public Health for a Healthier
health programs and services.
America. TFAH partnered with The New
Section 3: Trust for America’s
York Academy of Medicine to convene ex-
perts to inform, review, and develop cost esti-
Health Initiative Recommendations
mates based on the current total
A. Prevention for a Healthier America: In-
governmental investment in public health and
vestments in Disease Prevention Yield
the level of investment that would be required
Significant Savings, Stronger Communi-
to support a modernized public health system.
ties. Recommendations for a National Health
This section examines potential revenue
and Prevention Strategy
streams to support a sustained investment in
B. F as in Fat: How Obesity Policies Are
public health and examines how government
Failing in America. Recommendations for
funding must be a shared responsibility at the
a National Strategy to Combat Obesity
federal, state, and local levels.
C. Ready or Not? Protecting the Public’s
B. Federal Health Agencies:
Health from Diseases, Disasters, and
Restructuring for a Healthier America.
Bioterrorism. Recommendations for fixing
Recommendations for creating the optimal
the gaps in public health emergency
structure necessary to improve public
preparedness.
health programs and services across federal
government agencies, reflecting policy sug-
D. Fixing Food Safety: Protecting America’s
gestions from former high-ranking public of-
Food Supply from Farm to Fork.
ficials, former Members of Congress, and
Recommendations for improving food safety.
other opinion leaders.
E. Stamping Out Smoking. Recommenda-
C. Accountability for a Healthier America.
tions for policies to prevent smoking and
Recommendations for improving accounta-
other tobacco use.
bility across the public health system, so
F. Shortchanging America’s Health. Under-
Americans know what is being done to pro-
standing Social Determinants and Recom-
tect their health, how healthy the country
mendations for improving the health of all
and their communities are, and how effec-
Americans, no matter where they live.
tively their tax dollars are being used.
G. Healthy Women, Healthy Babies.
D. Meeting the Public Health Workforce
Recommendations for improving infant health
Crisis: Recruiting the Next Generation
in the U.S.
of Public Health Professionals. Recom-
mendations from public health and work-
Section 4: Overview of Federal
force experts for ways to recruit and retain
the next generation of public health profes-
Public Health Agencies and Budgets
sionals.
Section 5: Background Resources
E. Incorporating Public Health and Pre-
A. A Healthier America: An Agenda for
vention into Health Care Reform. Rec-
Modernizing Public Health. A summary of
ommendations on how strong public health
consensus-building meetings where more than
systems and public policies focused on pre-
35 leading health experts and national organi-
vention of disease and injury should be the
zations met to define the need and scope for a
cornerstone of a health care reform plan.
policy agenda to modernize public health.
3
The Trust for America’s Health (TFAH) would like to thank all of the
experts and organizations who contributed to the development of the
Blueprint. The opinions expressed in the Blueprint do not necessarily repre-
sent the views of these individuals or organizations.
Julio Abreu, Director of Government
Jim Blumenstock, Chief Program Officer,
Affairs, Mental Health America
Public Health Practice, Association of State
and Territorial Health Officials
Katie Adamson, Director of Health
Partnerships and Policy, YMCA of the USA
Ramon Bonzon, MPH, Program Associate,
National Association of County and City
Denise Adams-Simms, MPH, Executive
Health Officials
Director, California Black Health Network
Jo Ivey Boufford, MD, President, The New
Nancy Adler, PhD, Director, Center for
York Academy of Medicine
Health and Community, University of
California, San Francisco
Courtney Brein, Policy Associate, The New
York Academy of Medicine
Gregg Albright, Deputy Director, Planning
and Model Programs,California
Roderick Bremby, MPA, Secretary, Kansas
Department of Transportation
Department of Health and Environment
Brian Altman, JD, Director of Public Policy
Russell Brewer, DrPH, MPH, CHES,
and Program Development, Suicide
Program Associate, Robert Wood Johnson
Prevention Action Network USA
Foundation
Sharon Arnold, PhD, Vice President,
Eli Briggs, Senior Government Affairs
AcademyHealth
Specialist, National Association of County
and City Health Officials
Bernie Arons, MD, Executive
Director/CEO, National Development and
Charlotte Brody, RN, Executive Director,
Research Institutes, Inc.
Commonweal
Linnea Ashley, MPH, Program
Carol Brown, MS, Senior Advisor, National
Coordinator, Prevention Institute
Association of County and City Health
Officials
Ed Baker, MD, MPH, Director, North
Carolina Institute for Public Health
Donna Brown, JD, MPH, Government
Research Professor, University of North
Affairs Counsel and Senior Advisor for
Carolina School of Public Health
Public Affairs, National Association of
County and City Health Officials
Polly Bednash, PhD, RN, FANN, Executive
Director, American Association of Colleges
Maureen Budetti, MA, Director of Student
of Nursing
Aid Policy, National Association of
Independent Colleges and Universities
Suzanne Begeny, MS, RN, Director of
Government Affairs, American Association
Charlene Burgeson, Executive Director,
of Colleges of Nursing
National Association for Sport as Physical
Education
Georges Benjamin, MD, FACP, FACEP(E),
Executive Director, American Public Health
Terry Buss, PhD, Director, International
Association
Studies, National Academy of Public
Administration
Bob Berenson, MD, Senior Fellow, Urban
Institute
Jeremy Cantor, MPH, Program Manager,
Prevention Institute
Ron Bialek, MPP, President, Public Health
Foundation
David Chavis, PhD, Principal Associate and
CEO, Association for the Study and
Michael Bird, PhD, MSW, MPH, Private
Development of Community
Consultant
Jessica Donze Black, RD, MPH, Executive
Director, Campaign to End Obesity
4
Mary Gardner Clagett, Deputy Director for
David Fleming, MD, Director of Public
Policy, Workforce Development Strategies
Health, Seattle King County Public Health
Group, National Center on Education and
Sheila Franklin, Director, National
the Economy
Coalition for Promoting Physical Activity
Gabriel Cohen, Former Policy Associate,
Mark Friedman, Director, Fiscal Policy
The New York Academy of Medicine
Studies Institute
Larry Cohen, MSW, Executive Director,
Ana Garcia, MPA, Policy Associate, The
Prevention Institute
New York Academy of Medicine
John Colbert, JD, Senior Counsel, Workforce
Parris Glendening, President, Smart
Development Strategies Group, National
Growth Leadership Institute
Center on Education and the Economy
Eric Goplerud, PhD, MA, Research
Carrie Cornwell, Chief Consultant,
Professor, George Washington University
Transportation and Housing Committee,
School of Public Health and Health Services
California State Senate
Steve Gunderson, President and CEO,
Bill Corr, JD, Executive Director,
Council on Foundations
Campaign for Tobacco-Free Kids
Paul Halverson, DrPH, FACHE, Director
Rachel Davis, MSW, Managing Director,
and State Health Officer, Arkansas
Prevention Institute
Department of Health
Daniel Dawes, JD, Senior Legislative and
Peggy Hamburg, MD, Senior Scientist, NTI
Federal Affairs Officer, Public Interest
Policy, American Psychological Association
Dennis Harrington, Deputy Division
Director, North Carolina Division of Public
Linda Degutis, DrPH, MSN, Research
Health
Director, Yale Center for Public Health
Preparedness
Susan Hattan, MA, Senior Consultant,
National Association of Independent
Pat DeLeon, PhD, JD, MPH, Chief of Staff,
Colleges and Universities
Senator Daniel Inouye
Audrey Haynes, MSW, Senior Vice
Nancy-Ann DeParle, JD, MA, Managing
President for Government Relations, YMCA
Director, CCMP Capital, LLC
of the USA
Abby Dilley, MS, Senior Mediator,
Karen Helsing, MHS, Director, Educational
RESOLVE
Programs, Association of Schools of Public
Helen DuPlessis, MD, MPH, Assistant
Health
Professor, UCLA School of Medicine and
Jane Henney, MD, Professor for Health Affairs,
School of Public Health
University of Cincinnati College of Medicine
John Dwyer, JD, Special Advisor, Arent Fox
Peggy Honore, DHA, Associate Professor,
Thomas Elwood, DrPH, Executive
University of Southern Mississippi
Director, Association of Schools of Allied
Mark Horton, MD, MPH, State Public
Health Professions
Health Officer, California Department of
Gerard Farrell, Executive Director,
Public Health
Commissioned Officers Association of the
Anthony Iton, MD, JD, MPH, Director and
U.S. Public Health Service
Health Officer, Alameda County
Gerri Fiala, Former Director of Workforce
Department of Public Health
Research, Workforce Development
Megan Ix, Research Assistant,
Strategies Group, National Center on
AcademyHealth
Education and the Economy
Paul Jarris, MD, MBA, Executive Director,
Ruth Finkelstein, ScD, Vice President for
Association of State and Territorial Health
Health Policy, The New York Academy of
Officials
Medicine
Grantland Johnson, Special Advisor,
Sarah Flanagan, MAT, Vice President for
Strategy Policy, Community Housing
Government Relations and Policy, National
Opportunities Corporation
Association of Independent Colleges and
Universities
5
Nancy Johnson, Senior Public Policy
Joe Marx, Senior Communications Officer,
Advisor, Baker/Donelson
Robert Wood Johnson Foundation
Bill Kamela, Senior Director for Education
Barbara Masters, MA, Public Policy
and Workforce, Law and Corporate Affairs,
Director, The California Endowment
Microsoft
Glen Mays, MPH, PhD, Department of
Martha Katz, MPA, Director of Health
Health Policy and Management, Fay W.
Policy, Healthcare Georgia Foundation
Boozman College of Public Health
Rita Kelliher, MSPH, Director, Grants and
James McKenney, Vice President for
Contracts, Association of Schools of Public
Economic Development, American
Health
Association of Community Colleges
Norma Kent, Vice President of
Leslie Mikkelsen, MPH, Managing
Communications, American Association of
Director, Public Health Institute
Community Colleges
Wilhelmine Miller, MS, PhD, Associate
Andrew Kessler, JD Principal, Slingshot
Staff Director, Commission to Build a
Solutions, Inc.
Healthier America
David Kindig, MD, PhD, Emeritus Professor
Mark Mioduski, MPA, Vice President,
of Population Health Sciences and Emeritus
Cornerstone Government Affairs
Vice-Chancellor for Health Sciences,
Jack Moran, MBA, MS, PhD, Senior
University of Wisconsin-Madison, School of
Quality Advisor, Public Health Foundation
Medicine
Joyal Mulheron, MS, Program Director,
Laura Rasar King, MPH, CHES, Executive
Public Health, National Governors
Director, Council on Education for Public
Association
Health
Fran Murphy, MD, Independent Consultant
Yvonne Knight, Director, Government
Relations, National Academy of Public
Poki Stewart Namkung, MD, MPH, Health
Administration
Officer, County of Santa Cruz
Chris Koyanagi, Policy Director, Bazelon
Sandy Naylor-Goodwin, PhD, Executive
Center for Mental Health Law
Director, California Institute for Mental
Health
Vinnie Lafronza, EdD, MS, Co-Principal
and Founder, CommonHealth ACTION
Julie Netherland, MSW, Policy Associate,
The New York Academy of Medicine
Nina Leavitt, EdD, Associate Executive
Director for Government Relations,
Carmen Nevarez, MD, MPH, Vice
Education Directorate, American
President for External Relations and
Psychological Association
Preventive Medicine Advisor, Public Health
Institute
Melissa Lewis, MPH, Analyst, Public
Health, Association of State and Territorial
Kathleen Nolan, MPH, Director, Health
Health Officials
Division, National Governors Association
Patrick Libbey, Executive Director,
Delia Olufokunbi, PhD, MS, Assistant
National Association of County and City
Research Professor, Department of Health
Health Officials
Policy and Deputy Director of the Center
for Integrated Behavioral Health Policy,
Marsha Lillie-Blanton, DrPH, Senior Advisor,
George Washington University School of
Commission to Build a Healthier America
Public Health and Health Services
Nicole Lurie, MD, MSPH, Senior Natural
Barbara Ormond, PhD, Senior Research
Scientist and Co-Director for Public Health
Associate, Urban Institute
at the Center for Domestic and
International Health Security, RAND
Tara O’Tooke, MD, MPH, Chief Executive
Officer and Director, Center for Biosecurity
Ron Manderscheid, PhD, Global Health
Sector, Director of Mental Health and
Kate Froeb Papa, MPH, Senior Manager,
Substance Use Programs, SRA International
AcademyHealth
Jim Marks, MD, MPH, Senior Vice
Scott Pattison, Executive Director, National
President, Director Health Group, Robert
Association of State Budget Officers
Wood Johnson Foundation
6
Jim Pearsol, Chief Program Officer, Public
Brian Smedley, PhD, Former Research
Health Performance, Association of State
Director and Co-Founder, Opportunity
and Territorial Health Officials
Agenda
Robert Phillips, MPA, MPH, Senior
Jennifer Beard Smulson, Senior Legislative
Program Officer, The California
and Federal Affairs Officer, Government
Endowment
Relations Office, Education Directorate,
American Psychological Association
Sylvia Pirani, MPH, Director, Office of
Local Health Services, New York State
Gene Sofer, Partner, The Susquehanna
Department of Health
Group
Alonzo Plough, MA, MPH, PhD, Vice
Byron Sogie-Thomas, MS, Director of
President, Strategy, Planning, and
Health Policy, National Medical Association
Evaluation, The California Endowment
Brenda Spillman, PhD, Senior Research
Susan Polan, PhD, Associate Executive
Associate, Urban Institute
Director, Public Affairs and Advocacy,
Janani Srikantharajah, Program Assistant,
American Public Health Association
Prevention Institute
John Porter, JD, M.Ed, Partner, Hogan and
Laurel Stine, MS, JD, Director of Federal
Hartson
Relations, Bazelon Center for Mental
Margaret Potter, JD, Associate Dean
Health Law
and Director, Center for Public Health
Robin Squellati, RN, MSN, NP, Colonel,
Practice, University of Pittsburgh, School
U.S. Air Force Nurse Corps; Detailee to the
of Public Health
Office of U.S. Senator Daniel Inouye
Stephanie Powers, Project Director,
David Sundwall, MD, Executive Director,
National Fund for Workforce Solutions
Utah Department of Health
Carol Rasco, MA, President and CEO,
Mike Taylor, JD, Research Professor,
Reading is Fundamental
George Washington University School of
Judith Rensberger, MS, MPH, Government
Public Health and Health Services
Relations Director, Commissioned Officers
Pat Taylor, Executive Director, Faces &
Association of the U.S. Public Health Service
Voices of Recovery
Robert Rosseter, Associate Executive
Bob Templin, Jr., PhD, President,
Director, American Association of Colleges
Northern Virginia Community College
of Nursing
(NOVA)
Pamela Russo, MD, MPH, Senior Program
Annie Toro, JD, MPH, Associate Executive
Officer, Robert Wood Johnson Foundation
Director for Government Relations, Public
Judy Salerno, MD, SM, Executive Officer,
Interest Directorate, American
the Institute of Medicine of the National
Psychological Association
Academies
Ho Luong Tran, PhD, President and CEO,
Eduardo Sanchez, MD, MPH, Director,
Asian and Pacific Islander American Health
Institute for Health Policy, University of
Forum
Texas School of Public Health
John Vasquez, Solano County Supervisor
Bill Schultz, JD, Partner, Zuckerman Spaeder
Rajeev Venkayya, MD, Former Special
David Shern, PhD, President and CEO,
Assistant to the President and Senior
Mental Health America
Director for Biodefense, White House
Homeland Security Council
Gillian Silver, MPH, Manager, Research
and Educational Programs, Association of
Tim Waidmann, PhD, Senior Research
Schools of Public Health
Associate, Urban Institute
Paul Simon, MD, MPH, Director, Division
Tracy Wiedt, MPH, Program Manager,
of Chronic Disease and Injury Prevention,
YMCA of the USA
Los Angeles County Department of Public
Health
7
A. OUR VISION FOR A HEALTHIER AMERICA
America should strive to be the healthiest nation in the world. Every
American should have the opportunity to be as healthy as he or she
can be. Every community should be safe from threats to its health. And all
individuals and families should have a high level of services that protect, pro-
mote, and preserve their health, regardless of who they are or where they live.
To realize these goals, the nation must strengthen America’s public health sys-
tem in order to: 1) provide people with the information, resources, and envi-
ronment they need to make healthier choices and live healthier lives, and 2)
protect people from health threats beyond their control, such as bioterrorism,
natural disasters, infectious disease outbreaks, and environmental hazards.
Achieving this vision will require the combined efforts of federal, state, and
local governments in partnership with businesses, communities, and citizens.
The Problem and Need for Action
Today, serious gaps exist in the nation’s ability
ting millions of adults and children at risk
to safeguard health, putting our families, com-
for unprecedented levels of major diseases
munities, states, and nation at risk.
like diabetes and heart disease.
I Seven years after September 11, 2001, and
I Poor health is putting the nation’s eco-
three years after Hurricane Katrina, major
nomic security in jeopardy. The skyrock-
problems remain in our readiness to re-
eting costs of health care threaten to
spond to large-scale health emergencies.
bankrupt American businesses, causing
The country is still insufficiently prepared
some companies to send jobs to other
to protect people from disease outbreaks,
countries where costs are lower. Helping
natural disasters, or acts of bioterrorism,
people to stay healthy and better manage
leaving Americans unnecessarily vulnera-
illnesses are the best ways to drive down
ble to these threats.
health care costs. Keeping the American
I
workforce well helps American businesses
Even though America spends more than
remain competitive in the global economy.
$2 trillion annually on health care - - more
than any other nation in the world - - tens
America must provide quality, affordable
of millions of Americans suffer every day
health care to all. But that’s not enough.
from preventable illnesses and chronic dis-
The government must create strategies to
eases like cancer, diabetes, and
eliminate health disparities and improve the
Alzheimer’s that rob them of health and
health of all Americans, regardless of race,
quality of life. Racial, ethnic and eco-
ethnicity, or socioeconomic status. A strong
nomic disparities exacerbate the burden
public health system and public policies fo-
of disease. Baby boomers may be the first
cused on prevention of disease and injury
generation to live less healthy lives than
must be part of the solution.
their parents. And, the obesity crisis is put-
9
Guiding Principles for Prevention
Preventing and combating threats to our
ment that work in collaboration with health
health is the primary responsibility of our na-
care providers, businesses, and community
tion’s public health system. The public
partners. Achieving a healthier America re-
health system consists of health agencies at
quires a national commitment to revitalizing
the federal, state, and local levels of govern-
and modernizing the public health system.
1. We believe prevention must drive our nation’s health strategy.
I Our support for health care has focused
I Fundamentals like investigating epidemics,
for too long on caring for people after
educating the public about health risks,
they become sick or harmed. Prevention
early screening for disease, and immuniza-
means improving the quality of people’s
tions are proven to help prevent and re-
lives, sparing individuals from needless suf-
duce the rates of illness and disease. A
fering, and eliminating unnecessary costs
greater emphasis on prevention could sig-
from our health system.
nificantly reduce rates of chronic illness.
2. We believe Americans deserve healthy and safe places to live, work, and play.
I By supporting policies and programs like
I The government must protect air, water, and
promoting healthier schools, smoke-free
food; minimize chemical exposures; and pro-
environments, and improved community
vide communities healthier environments.
design, the government can do more to
meet its responsibility to help citizens lead
healthier lives.
3. We believe every community should be prepared to meet the threats of infectious
disease, bioterrorism, and natural disasters.
I A basic role of government is to protect us
rorism and infectious disease outbreaks,
and our health from threats like bioter-
and to keep our food supply safe.
4. We believe Americans deserve to know what government is doing to keep them
healthy and safe.
I The federal government’s role is to ensure
countable for the health and safety of the
that the public health system has sufficient
American people. And, the government
resources and meets basic standards for
must show that it is spending public health
protecting the public’s health. Govern-
dollars effectively and in ways that clearly
ment at all levels must also be held ac-
improve the public’s health and safety.
10
WE, THE UNDERSIGNED, ARE PROUD TO BE SIGNATORIES TO THIS VISION
FOR A HEALTHIER AMERICA:
AARP • Active for Life • AIDS Action Council • Allergy & Asthma Network Mothers of
Asthmatics • Alliance for Healthy Homes • America Walks • American Academy of Pediatrics
• American Alliance for Health, Physical Education, Recreation and Dance • American
Association for Homecare • American Association of Occupational Health Nurses, Inc. •
American Cancer Society-Cancer Action Network • American College of Clinical Pharmacy •
American College of Occupational and Environmental Medicine • American College of
Preventive Medicine • American Diabetes Association • American Federation of State, County
and Municipal Employees (AFSCME) • American Heart Association • American Institute for
Medical and Biological Engineering • American Lung Association • American Nurses
Association • American Osteopathic Association • American Optometric Association •
American Pharmacists Association • American Public Health Association • American Red
Cross • American School Health Association • American Tai Chi Association • Amputee
Coalition of America • Association for Prevention Teaching and Research • Association for
Professionals in Infection Control and Epidemiology • Association of Maternal and Child
Health Programs • Association of Public Health Laboratories • ssociation of Schools of Public
Health • Association of State and Territorial Directors of Nursing • Association of State and
Territorial Health Officials • Association of State and Territorial Public Health Nutrition
Directors • Association of Women’s Health, Obstetric, and Neonatal Nurses • Autism Society
of America • Bauman Family Foundation • Breast Cancer Fund • California Communities
Against Toxics • The California Endowment • Campaign for Tobacco-Free Kids • Campaign
to End Obesity • CDC Foundation • Center for Behavioral Epidemiology and Community
Health, Graduate School of Public Health, San Diego State University • Center for Biosecurity,
University of Pittsburgh Medical Center • The Center for Infectious Disease Research and
Policy, University of Minnesota • Center for Science in the Public Interest • Childbirth
Connection • CityMatCH • Clean Water Action • Commissioned Officers Association of the
U.S. Public Health Service • Commonweal • Defeat Diabetes Foundation • Directors of Health
Promotion and Education • Environmental Defense • Every Child By Two • FamilyCook
Productions • Families Against Cancer & Toxics • Families in Search of Truth • The Federation
of American Scientists • First Focus • Fit & Able Productions, Inc. • Florida Hospital
Celebration Health • Georgia Public Health Association • Grantmakers In Health • Healthy
Homes Collaborative • Hepatitis B Foundation • HIV Medicine Association • Home Safety
Council • Immunization Action Coalition • Ingham County (MI) Health Department •
Institute for Agriculture and Trade Policy • Institute for Children’s Environmental Health •
Institute of Food Technologists • International Health, Racquet, & Sportsclub Association •
International SPA Association • International SPA Association Foundation • Leadership for
Healthy Communities • League of American Bicyclists • Lose to Live Inc. • M+R Strategic
Services • Marathon Kids • March of Dimes Foundation • Micah’s Mission (Ministry to
Improve Childhood & Adolescent Health) • My Brother‘s Keeper, Inc. • National Alliance of
State and Territorial AIDS Directors • National Association for Public Health Statistics and
Information Systems • National Association of Chronic Disease Directors • National
Association of Community Health Centers • National Association of County and City Health
Officials • National Association of Local Boards of Health • National Association of State EMS
Officials • National Center for Bicycling & Walking • National Center for Healthy Housing •
National Coalition for LGBT Health • National Coalition for Promoting Physical Activity •
National Council on Aging • National Disease Clusters Alliance • The National Environmental
Health Association • National Hispanic Medical Association • National Network of Public
11
Health Institutes • National Nursing Centers Consortium • National Nursing Network
Organization • National Physicians Alliance • National Public Health Information Coalition
• National Recreation and Park Association • National Research Center for Women & Families
• National Tuberculosis Controllers Association • The National Urban League • National WIC
Association • Nemours Health and Prevention Services • The New York Academy of Medicine
• New York State Nutrition Council • Partners for a Healthy Nevada • Partnership for
Prevention • Physicians for Social Responsibility • The Praxis Project/Path • Prevent Blindness
America • Prevention Institute • Preventive Cardiovascular Nurses Association • Public Health
Foundation • Research!America • Researchers Against Inactivity-Related Disorders • Robert
Wood Johnson Foundation • Samuels & Associates • Safe Routes to School National
Partnership • Shaping America’s Health • Society for Adolescent Medicine • Society for
Advancement of Violence and Injury Research • Society for Public Health Education • The
South Carolina Eat Smart, Move More Coalition • Sporting Goods Manufacturers Association
• The Sports Karma Foundation • Trust for America’s Health* • Tulane Center for Applied
Environmental Public Health • United States Water Fitness Association • University of
Arkansas Fay W. Boozman College of Public Health • Vegetarian Resource Group •
Washington Health Foundation • Women’s Sports Foundation • YBH (Youth Becoming
Healthy) Project, Inc. *The Healthier America Project is organized by the Trust for America’s Health.
* The signatories above support this vision statement (Section 1A of the report). The recommendations
and opinions expressed in the full Blueprint do not necessarily represent the views of these organizations.
12
Section 2
I N F R A S T R U C T U R E SECTION
R E C O M M E N D AT I O N S
2
SECTION
2
Infrastructure
Recommendations
2
S E C T I O N
A. FUNDING PUBLIC HEALTH FOR A
HEALTHIER AMERICA
Public health is chronically underfunded in
Current federal, state, and local public
the U.S. There is currently a shortfall of $20
health spending is approximately $35 billion
billion per year in spending on public health,
per year - - more than $120 per person.3 The
according to an analysis by The New York
federal government provides nearly 60 per-
Academy of Medicine (NYAM) and Trust for
cent of these funds, and state and local gov-
America’s Health (TFAH) conducted in con-
ernments provide the other 40 percent. This
sultation with a panel of experts.
spending represents approximately 1.78 per-
cent of total National Health Expenditure
The analysis found that federal, state, and
Accounts (NHEA).4
local public health departments are unable
to adequately carry out core functions at cur-
Based on a review of prior analyses and con-
rent funding levels, including:
sultation with the panel of 15 leading public
I
health experts about the best ways to deter-
Monitoring the health of the public;
mine the public health funding shortfall, the
I Enforcing public health laws;
researchers conducted two analyses:
I Diagnosing and investigating health prob-
1) A review of public health spending in other
lems in the community;
Organization for Economic Cooperation and
I
Development (OECD) countries, which ranges
Mobilizing community partnerships;
from 1.1 percent to 6.1 percent of national
I Developing policies that support individ-
health expenditures. If the U.S. spent near the
ual and community health efforts;
average of these countries (three percent of
I
NHEA), it would equal $59 billion, an increased
Linking people to needed health services;
investment of $24 billion annually;5 and
I Assuring a competent public health and
2) A review of a detailed needs assessment in
individual health care workforce;
Washington State.6 This study found that an
I Evaluating effectiveness, accessibility, and
estimated additional investment of $400 mil-
quality of individual and population-based
lion dollars is needed yearly “to meet the
health services; and
[Washington State Public Health] standards 95
I
[percent] of the time throughout the state.”7
Researching new insights and innovative
This would equate to an additional $64 per per-
solutions to health problems.2
son per year or $18 billion per year nationally.
13
Federal, state, and local governments should:
I Increase public health funding to ade-
this level of increased investment and ex-
quately support core functions. The coun-
pansion of services. Based on the current
try should spend a total of $55 to $60
funding model, the federal government
billion annually (approximately $187 per
should provide 60 percent of this increase
person) on public health to adequately
- - an additional $12 billion annually - - and
prevent disease and protect Americans
state and local governments should pro-
from disease threats. TFAH estimates it
vide 40 percent of this increase -- $8 billion
would take four to five years for the public
annually. (See Section 4 for federal health
health system to absorb and grow to meet
agency budgets.)
Potential Revenue Streams For the Increased Funds Could Include:
The following are a series of options for ways
Existing Funding Streams and Public
to finance an increased investment in public
Health Programs: Federal Level
health. Either individually or cumulatively,
Create a guaranteed funding stream for pre-
the goal should be increasing federal spend-
vention and public health activities by tapping
ing for public health by $12 billion. In-
Medicare, Medicaid, and private payers, as
creases should be made over a period of
well as public health dollars.
years to build to this level of funding.
I Wellness Trust
Over the past five years, federal funding for
The Brookings Institution’s Hamilton Pro-
public health has not kept pace with inflation.
ject’s proposal for a Wellness Trust is one po-
$2.58 billion - - which is 21.5 percent of the
tential model for establishing a revenue
$12 billion -- is needed just to restore key pub-
stream to support clinical and community-
lic health agencies to funding levels in 2005.
based prevention.8, 9
The Wellness Trust would ensure every Amer-
munity walking programs. The Trust would
ican has access to a core set of proven preven-
then become the primary payer for these serv-
tive care services, including immunizations
ices for all Americans, and it would also have
and clinical prevention, screenings, and health
the authority to provide funding for infra-
counseling. The set of services would be de-
structure improvements.
cided by a set of expert Trustees, based on the
The Wellness Trust would be governed by an
most effective and highest-impact types of pre-
independent entity, would be authorized to re-
vention, such as breast cancer screenings,
spond to Congress without review from the U.S.
pneumonia vaccinations for seniors, and com-
14
Department of Health and Human Services
Congress could create a new structure is by
(HHS), and would have independent rule-mak-
creating a Healthy Living, Healthy Aging
ing authority It would be similar to the Boards
pilot program for pre-Medicare-eligible
of Trustees of the Social Security and Medicare
Americans to invest in proven community-
Trust Funds, or the Federal Reserve. Support
based disease prevention programs to help
for the Wellness Trust would come from feder-
prevent disease and promote better health
ally-funded health agencies and private insur-
for Americans under the age of 65, poten-
ers determining their spending and resulting
tially focusing on individuals between 55
savings from preventive services. The amount
and 64 years old. This investment would
the federal government spends on priority pre-
show a return in savings for Medicare, since
vention services would determine the budget
it would reduce the rates of disease and
authorization for the Wellness Trust. Funding
keep people healthier as they age. CMS
would come from general revenue, in a process
should contract with eight or fewer state or
similar to how Medicare is funded, and would
local health departments to support com-
increase annually by the estimated projected
munity-based anti-smoking, physical activity,
growth in national health expenditures.
and nutrition initiatives that have demon-
strated the capacity to prevent and/or mod-
I Medicare
ify chronic disease risk factors. Public health
By the time they are eligible, millions of
departments should conduct community
Americans enter Medicare with conditions
screenings of the targeted population to as-
that could have been lessened or prevented.
sess healthy behaviors and measure blood
In the end, Medicare -- and taxpayers -- bears
pressure, cholesterol, blood sugar, and
the cost burden of providing for people who
other chronic disease risk factors.
could be significantly healthier or have their
existing conditions much better managed.
I Medicaid
A similar rationale exists for a Medicaid in-
Medicare has a direct interest in assuring a
vestment in certain communities. Medicaid
healthier aging population. If Americans are
programs could see a return on investment
healthier when they reach the age of 65, it
on community-level prevention initiatives
could save Medicare billions of dollars. An en-
that would reach beyond the Medicaid pop-
hancement of preventive care services -- for
ulation. If preventive efforts can help stop
people both under and over the age of 65 -- is
some people from developing disabilities,
long overdue, as this approach will ultimately
this could also prevent these individuals from
save money and lead Americans down the road
becoming Medicaid eligible, which would
to longer, healthier lives. This would require a
create additional cost savings. Policy changes
change in policy regarding the appropriate tar-
would be needed to permit financing com-
get of Medicare-funded initiatives, looking at
munity-level prevention services under Med-
funding efforts to improve the health of Amer-
icaid, but this would ensure an increased
icans before they reach the age of 65 as well as
investment by both the federal and state gov-
once they are Medicare-eligible. Two very dif-
ernments. Approaches similar to those out-
ferent approaches could be taken:
lined for Medicare should be considered:
I Tapping a percentage of Medicare spend-
I Tapping a percentage of federal Medicaid
ing and allocating those resources to fund
spending (with a required state match)
public health programs. Medicare would
would create substantial new resources for
more than likely recoup the investment in
public health programs.
future savings.
I
I
Creating demonstration or pilot programs
Creating a “prevention initiatives” demon-
similar to the Medicare program above to
stration pilot program with direct support
help resolve issues of who is a Medicaid
from the Centers for Medicare and Medi-
provider and how reimbursement can be
caid Services (CMS). One example of how
handled.
15
I Setting up Medicaid Administrative Ac-
less than 0.2 percent and no more than one
counts. States currently use federal Medi-
percent of the total PHS program budget) to
caid matching funds to reimburse a
increase support for core public health and
portion of administrative costs. This reim-
preventive services.10 As new mechanisms
bursement effectively underwrites many
are developed, existing programs require ad-
state and local health programs. Some of
ditional funding. While choices need to be
this matching amount could be designated
made based on priorities and effectiveness, a
to support prevention-related programs.
substantial investment is needed to make up
for recent cuts in many federally-funded pub-
I Existing Federal Public Health Programs
lic health programs. Congress and the Ex-
Opportunities exist, through traditional
ecutive Branch should commit to indexing
funding mechanisms (e.g., discretionary
future public health spending to increases in
spending or the Public Health Service (PHS)
national health expenditures overall.
evaluation tap, which by statute can be no
Supporting State Initiatives
The federal government can play a critical
federal resources. Some adjustments in the
role in incentivizing states and localities to
matching requirement could also be made
increase their investment in public health.
for those states that are already spending
The NYAM and TFAH analysis has shown
higher levels so that the MOE does not serve
that on average states and localities provide
as a disincentive for funding. As long as pub-
about 40 percent of revenues for public
lic health remains a shared federal-state-local
health programs.
responsibility, all players must step up to the
plate and increase their level of investment.
I Create a matching requirement for grant -
ees receiving increased federal funding
I State- or Community-Level Equivalent of
There is a wide variation in the level of in-
the Wellness Trust
vestment by states and localities in public
The federal government could provide seed
health. States and localities would be re-
money for the formation of a public-private
quired to provide a match to receive new fed-
partnership agency at the state- or community-
eral money, reflecting the 60 percent federal
level modeled on a national Wellness Trust. It
and 40 percent state-local investment that
would create an infrastructure to receive vol-
currently exist. The actual state match could
untary and/or mandatory contributions to en-
be adjusted in a manner similar to the Med-
sure coordination and make decisions about
icaid program. States should be required to
investments. Additionally, federal matching
maintain existing investment (maintenance
funds could serve as an incentive to states and
of effort or MOE) in exchange for increased
localities to create such an entity.
16
Possible Options for New Revenue Streams
I Surcharges on Health Care Funding
foods and also make Americans healthier
Mechanisms
if the revenue from these taxes were ear-
Private insurers, not just Medicare and Medi-
marked for prevention. Yale University re-
caid, benefit from public health spending.
searchers estimate that a national tax of as
Mechanisms should be explored to ensure
little as one cent on soda, candy, and other
they contribute in some way to community-
snack foods could raise nearly $2 billion a
level public health interventions. A surcharge
year.11 As one example, in May 2004, the
could be placed on employer-sponsored in-
University of Virginia Health System began
surance (including Department of Defense
adding warning labels to its vending ma-
health coverage and the Federal Employee
chines and charging a five cent tax on the
Health Benefits Plan), which could be waived
least healthy items. In one year, con-
if insurers agree to a “prevention investment
sumption of these snacks fell by five per-
package,” which could include:
cent and $6,700 was raised, which was
donated to a children’s fitness program at
I First-dollar coverage for all age-appropriate
the university.12
prevention services, recommended by the
U.S. Preventive Services Taskforce, including
I Tobacco taxes, which have been shown to
immunizations and screening;
reduce smoking, and in many states, could
be used to help to fund health programs.
I Contributions (amount determined by
insurer size) to local community-based
I Federal alcohol taxes are at historically low
prevention efforts (such as a local wellness
levels and they are inconsistently levied on
trust);
beer, wine, and liquor. Equalizing federal
excise taxes could raise nearly $8 billion,
I Employee wellness program (meeting best
increasing public health funding while at
practices standards) offered free to all com-
the same time reducing alcohol-related in-
panies they insure and to their workers; and
juries, suicides, and unhealthy alcohol use.
I First-dollar coverage for maintenance drugs,
I Food advertising profits tax, which annually
such as high blood pressure medication.
is nearly $11 billion in spending on direct
media advertising in the U.S. Nearly 70 per-
I Taxes That Can Help Influence Behavior
cent of that amount is spent on conven-
Certain taxes can be used to promote healthy
ience foods, candy snacks, alcoholic
behaviors while also providing revenue for
beverages, soft drinks, and desserts.13 Prof-
public health programs. Options include:
its media outlets make from these sales
I Soda and candy or snack taxes, which
could be taxed.
could reduce consumption of unhealthy
17
METHODOLOGY FOR GENERATING THE ESTIMATE OF
CURRENT INVESTMENT
The New York Academy of Medicine con-
State and local health departments vary
ducted an extensive review of the literature
greatly in the services they offer and under-
to identify previous methods for estimating
write. Some, but not all, state and local health
government investment in public health. In
department budgets may reflect investment
September 2007 and January 2008, an expert
in primary care, mental health care, sub-
panel was convened to provide input on the
stance abuse prevention and treatment, and
previous attempts and develop consensus on
environmental health. However, the available
the approach for this project. The panel
data sources did not allow for the examina-
agreed none of the existing approaches was
tion of program-level spending by state or
adequate and recommended that the new
local health departments or to determine the
estimating methodology used for this project
investment in a particular set of services.
should be simple and should rely on existing
sources of data.
Local Investment
The New York Academy of Medicine ob-
Source: 2005 National Profile of Local Health
tained local-, state-, and federal-level esti-
Departments by the National Association of
mates of investment in public health and
County and City Health Officials (NAC-
summed these to generate the current na-
CHO).14 Local spending on public health is
tional public health investment estimate.
an estimated $3,974,222,981, or $15.19 on a
I
per capita basis.
Estimates excluded investment by non-
government agencies. The estimates did
State Investment
not include tribal contributions. Since the
analysis was primarily concerned with the
Source: Shortchanging America’s Health
role of government in public health, it did not
2006, a TFAH report of publicly-available
include investment by non-government ac-
2005 budget documents.15 The state-level
tors such as community organizations, foun-
data provided by TFAH excluded federal sup-
dations, or private firms. Investments made
port and Medicaid. The state expenditures
by these agencies are difficult to quantify and
were added together to generate a national
do not reflect government investment.
total of state investment in public health
($9,656,746,136). The per capita state in-
I Estimates only examined health depart-
vestment in public health totaled $33.14.16
ment budgets. While the health of the
public can be promoted through various
Federal Investment
agencies, such as departments of education,
transportation, agriculture, and the environ-
Sources: Fiscal year (FY) 2005 U.S. Depart-
ment, this project aims to determine the
ment of Health and Human Services budget
support provided to core public health func-
documents, including agencies most directly re-
tions typically carried out through local,
sponsible for funding local and state health de-
state, and federal public health departments.
partment infrastructure and programs (Centers
for Disease Control and Prevention (CDC),
I Estimates excluded funding of personal
Health Resources and Services Administration
health care services to the extent pos-
(HRSA), Substance Abuse and Mental Health
sible. At all levels of government, Medi-
Services Administration (SAMHSA), and Fed-
caid-supported activities were considered
eral Drug Administration (FDA), and the Indian
as personal health care services. To the ex-
Health Service (IHS) (excluding IHS clinical
tent allowed by the data sources, these
services).17 The total was $21,567,000,000
were excluded from the estimates. In some
($22 billion) -- or $72.89 per person.
cases, health departments provide and fund
direct, personal health care services, such
Individual states vary greatly in the share of
as sexually transmitted disease treatment
public health funded by different levels of
and prevention. The expenditures for
government. The national figures are a com-
these services were included in the analysis
posite that is not representative of the fed-
because they could not be disaggregated
eral, state, and local share in any one state.
within health department budgets.
18
B. FEDERAL HEALTH AGENCIES: RESTRUCTURING
FOR A HEALTHIER AMERICA
The federal government is responsible for
healthy a person is. Improving the health of
protecting the health of Americans. But the
Americans will require thinking in a new way
federal public health structure is broken and
where government agencies work together.
needs to be fixed.
Millions could be spared from needless suf-
Federal health agencies set national priori-
fering by increasing physical activity and
ties and goals for the country’s health, in-
good nutrition and reducing tobacco use
cluding reducing disease rates, and
and injuries. And, in addition to improving
providing funding and other support to
health, keeping Americans healthier is one
states and communities that carry out many
of the most important ways the country
programs and services directly aimed at im-
could significantly reduce health care costs.
proving health in the U.S.
The country’s health agenda has become so
The U.S. Department of Health and Human
dominated by managing the high costs and
Services (HHS) has outlined top priority ob-
treatment of health problems, that preventing
jectives aimed at reducing the main causes of
disease and helping Americans stay healthier
death through a Healthy People initiative,
only receives a small fraction of attention and
which they revise every 10 years. Unfortu-
funding support. The way federal health agen-
nately, the country has failed to achieve nearly
cies are currently structured and funded, they
70 percent of these goals.18 And, 15 of these
do not have the resources or jurisdiction nec-
health targets, including diabetes and obesity
essary to reach our national objectives for im-
rates, have gotten worse.19 It is clear that the
proving health. In particular, the public
current structure, where HHS is expected to
health service is underfunded, understaffed,
address health problems in isolation, is not
and often using out-of-date technologies to
working. A wide range of factors impact how
combat today’s modern health threats.
FEDERAL GOVERNMENT PUBLIC HEALTH RESPONSIBILITIES20
In partnership with states and localities, the
I Act to assist the states when they do not
federal government has an obligation to:
have the expertise or resources to mount
I
an effective response in a public health
Ensure all levels of government have the
emergency such as a disaster, bioterrorism,
capabilities to provide essential public
or an emerging disease; and
health services;
I
I Facilitate the formulation of public
Act when health threats may span many
health goals in collaboration with state
states, regions, or the whole country;
and local governments and other relevant
I Act where the solutions may be beyond
stakeholders.
the jurisdiction of individual states;
Examples of Budgets for HHS Agencies
Agency
Fiscal Year 2008 Appropriations
Centers for Medicare and Medicaid Services
$608 billion
National Institutes of Health
$29.5 billion
U.S. Centers for Disease Control and Prevention
$9.2 billion
Substance Abuse and Mental Health Services Administration
$3.4 billion
Health Resources and Services Administration
$6.9 billion
U.S. Food and Drug Administration
$2.3 billion
Total U.S. Department of Health and Human Services
$731 billion
Source: Budget in Brief, Department of Health and Human Services, FY 2008.
19
Trust for America’s Health (TFAH) consulted
I Understaffing; and
a wide, bipartisan range of current and former
I Limited coordination within health agen-
HHS and White House officials, state and local
cies and poor coordination across agencies
health officials, and other experts in public
in the federal government.
health policy to identify limitations with the
current federal structure, and recommenda-
To improve leadership and coordination,
tions for changes. Major problems include:
and to place a stronger emphasis on disease
I
prevention, TFAH assembled the following
Lack of clear, strong leadership;
recommendations for the federal govern-
I Insufficient focus on disease prevention,
ment. These recommendations represent a
one of the most important ways to reduce
set of options that could be addressed to-
health care costs;
gether as a whole or individually.
CHANGES AT THE WHITE HOUSE
The President should publicly acknowledge that improving the health of Americans is a
national priority and should:
I Appoint a Secretary of HHS who has a
L Creating strategies for improved coor-
strong understanding of public health as
dination among federal, state, and local
well as health care and will ensure that
levels of government, and ensure that
public health is central to the setting of de-
federal funds are used effectively by
partmental goals and objectives.
state and local recipients.
I Create a Public Health Taskforce within 90
I Issue an Executive Order that declares keep-
days of taking office. The Taskforce
ing America healthier as a national priority.
would provide recommendations for the
This Order should require fast-tracking pol-
structure of a new public health entity
icy changes and placing public health ex-
within 120 days of appointment to the
perts on the staffs of the White House
President and Congress. Responsibilities
Domestic Policy Council, National Eco-
for this new entity should include:
nomic Council, Homeland Security Council,
L Setting national short- and long-term
and National Security Council, in addition
public health goals, with special em-
to the expertise already housed in the Office
phasis on communities with the most
of Management and Budget (OMB).
significant health problems.
I At OMB, it is important to retain the ex-
L Providing policy, budget, and organiza-
pertise and structure on budget, manage-
tional recommendations to the Presi-
ment, and regulatory matters so that
dent and Congress.
health is considered in an integrated way
L Assessing the current status of federal,
and extends beyond health financing and
state, and local public health capacity,
the funding of biomedical research.
identifying key weaknesses and gaps,
and providing recommendations for
strengthening capacity.
20
THREE POTENTIAL MODELS FOR A NEW NATIONAL PUBLIC
HEALTH LEADERSHIP
I A National Public Health Board (NPHB) convened by the President to serve as an
independent voice on the state of the nation’s health. A NPHB would bring needed
oversight capacity to the sprawling public health system and would address the nation’s most
pressing health issues. Currently, such a body does not exist, and there is little coordination
or leadership at the federal agency to drive public health practices throughout the country.
I A Public Health Advisory Commission (PHAC) as an independent congressional
agency to advise the U.S. Congress. This new Commission would provide public health
expertise to Members of Congress as well as oversight capacity to the broad public health
system. This agency would be similar to the Medicare Payment Advisory Committee (Med-
PAC), which conducts wide-ranging analysis and offers recommendations to the Congress
regarding the Medicare program.
I A National Public Health Council (NPHC) created and convened by the Secretary
of HHS. The Council would convene state and local health commissioners and members of
the federal government at regular forums on at least an annual basis. The Council would
focus primarily on federal, state, and local interaction, and secondarily on federal issues.
CHANGES AT HHS
In an effort to strengthen prevention and pub-
L The Surgeon General oversees the Pub-
lic health at HHS, a number of actions should
lic Health Service Commissioned Corps,
be taken. The next Administration should:
which must be reinvigorated by lifting the
I
cap on the number of active members
Elevate the current Assistant Secretary for
and creating more flexibility and provi-
Health position to be an Undersecretary for
sions for backup service. Currently, the
Health (USH). This office should oversee a
Corps is underfunded, understaffed, and
strategic approach to prevention, prepared-
often uses out-of-date technology.
ness, and public health to increase coordi-
nation and accountability among agencies,
L The Surgeon General should also support
including all Public Health Service agencies,
the visibility of state and local health de-
the Assistant Secretary for Preparedness and
partments as critical parts of the public
Response, and the Centers for Medicare and
health system.
Medicaid Services reporting to this official.
I Clearly define public health emergency
The USH is not meant to disempower agen-
preparedness and response roles and re-
cies or add another bureaucratic layer, but
sponsibilities. Many experts have called
to help coordinate and provide leadership.
for more clarity around the roles and re-
Further, the USH and the Secretary would
sponsibilities of federal agencies involved
have integrated budget and policy analysis
in public health emergency preparedness,
staff so as not to have two layers of review.
including the Departments of HHS,
I Appoint a strong, independent Surgeon
Homeland Security (DHS), Veterans Af-
General who would be given the author-
fairs (VA), and Defense (DOD), and in of-
ity and resources to strengthen the Public
fices within HHS - - the Assistant Secretary
Health Service Commissioned Corps.
for Preparedness and Response (ASPR),
L
the Centers for Disease Control and Pre-
The Surgeon General must be given the
vention (CDC), and the Health Resources
independence to speak directly to the
and Services Administration (HRSA).
public on matters of health, and be given
the resources needed to ensure those
messages are heard.
21
L Under the current structure, ASPR func-
change expertise and experience, and
tions as both a policy arm and an operating
help to increase state and local effective-
division. As a policy office, it recommends
ness, capacity for innovation, and adop-
and oversees policy for all HHS agencies
tion of national health priorities.
and interacts with other cabinet agencies
I Establish a new public health research in-
and the White House on preparedness is-
stitute. This institute could create and dis-
sues. As an operating division, it manages
seminate public health best practices and
some programs including hospital pre-
provide states and localities with the data
paredness grants. Some officials have sug-
they need to make decisions about imple-
gested that all preparedness grants should
menting policies and programs. The in-
be managed by ASPR rather than CDC,
stitute would also help ensure greater
even though CDC has traditionally func-
accountability for the use of tax dollars.
tioned as an operating division and has ex-
pertise in managing grants. Roles must be
I Address workforce gaps and improve train-
clarified. With support from a new Under-
ing and coordination throughout HHS.
secretary of Health, ASPR should focus on
L Make recruiting and retaining a new gen-
consistency in policy among programs, to
eration of public health professionals a
ensure that all HHS agencies follow the pol-
high priority, in order to meet the im-
icy guidance of ASPR. CDC should con-
pending shortage of public health workers.
tinue to be the main operating division for
L Create a public health “boot camp” where
preparedness grants, to avoid adding more
all HHS employees can learn about public
bureaucracy and confusion for state and
health programs, including explanation of
local government grantees.
state and local responsibilities.
I Foster collaboration between federal,
L Give federal public health employees op-
state, and local officials. This would help
portunities to participate in leadership
enable public health authorities to ex-
training programs.
STRENGTHENING THE PUBLIC HEALTH SERVICE COMMISSIONED CORPS
The Public Health Service Commissioned
Former armed services members may
Corps is the nucleus of the federal govern-
lose their rank if they do not enter the
ment’s public health workforce.
Corps through an inter-service transfer.
I
Because of the cap on Corps members,
The Corps is one of the nation’s seven uni-
inter-service transfers have become rare.
formed services. It consists of 11 cate-
gories of public health professionals, such
I New hires to the Corps typically begin as
as physicians, pharmacists, environmental
reservists, and it often takes years to be-
health experts, nurses, veterinarians, and
come an active service member because
mental health professionals.
of the cap mentioned above.
I There is a Congressionally-mandated cap of
I Active Corps members are deployed when
2,800 “active” members for the Corps.
public health emergencies occur, such as
There are an additional 3,200 reservists and
during Hurricanes Ike, Gustav, and Katrina,
another 3,000 inactive or retired members,
the Indian Ocean tsunami in 2004, and Sep-
who may also hold positions within the
tember 11 and the anthrax attacks in 2001.
public health service, but they are not part
I Two-thirds of the active duty Corps mem-
of the “active” Corps.21 Reservists are less
bers are part of the Indian Health Service.
likely to receive promotions and have less
job protection during force reductions.
I Salaries for Corps members and reservists
I
are paid by the agencies where they work;
Routinely, an estimated 25 percent of new
there is no direct or dedicated funding for
Corps members transition into their posi-
the Corps.
tions after serving in the armed forces.22
22
PUBLIC HEALTH AT HHS
The federal agency with primary responsibility for public health activities is HHS. Within HHS,
the Public Health Service (PHS) conducts various health functions including disease control,
health regulation, research and direct provision of services. The PHS is an essential compo-
nent of all federal efforts to promote health and prevent disease.23 Eight agencies, currently
reporting to the HHS Secretary, comprise the PHS:
I Agency for Healthcare Research and Quality (AHRQ)
I Agency for Toxic Substances and Disease Registry (ATSDR)
I U.S. Centers for Disease Control and Prevention (CDC)
I U.S. Food and Drug Administration (FDA)
I Health Resources and Services Administration (HRSA)
I Indian Health Service (IHS)
I National Institutes of Health (NIH)
I Substance Abuse and Mental Health Services Administration (SAMHSA)
The Office of Public Health and Science (OPHS), the Office of the Assistant Secretary for
Preparedness and Response (ASPR), and Office of the Assistant Secretary for Health (ASH)
are other offices in HHS with important public health responsibilities.
Public health is primarily federally-funded through two types of grants:
I Categorical grants, which provide funds for a specific purpose and restrict states’ discre-
tion and increase federal oversight, and
I Block grants, created in the early 1980s, to achieve greater flexibility in the use of funds, to use
tax dollars more efficiently, and to provide more cost-effective services.
While the Centers for Medicare and Medicaid (CMS) is not part of the PHS, it does play an im-
portant role in keeping the public healthy through the preventive health services that are and
are not covered by Medicare and Medicaid programs.
GOVERNMENT-WIDE CHANGES
I The new Undersecretary of Health and the
I Health improvement reviews should also
new public health experts at the White
be conducted for all new domestic poli-
House should be charged with convening a
cies, with a goal of improving health and
sub-Cabinet Working Group across all
reducing health disparities. Reviews are
federal agencies to encourage consideration
expressly not intended to increase barriers
of the health impact of all policies and
to public health initiatives.
programs.
I The Office of Personnel Management
I An Office of Health Policy should be cre-
(OPM) should also ensure that the federal
ated in all Cabinet departments. These of-
government sets an example as an em-
fices would evaluate the health impact of
ployer. Worksite wellness programs and
policies and programs within each depart-
supportive preventive health insurance
ment. Commissioned Corps Officers
benefits should be made available to all
should staff such offices.
federal employees.
23
PUBLIC HEALTH AT FEDERAL AGENCIES BEYOND HHS
In addition to HHS, numerous federal offices have some part
Emergency Preparedness and Response, works to
in public health protection; over 50 agencies and departments
prevent terrorist attacks and plan for effective response
are involved in some aspect of public health. This list provides
procedures to threats. Specific health-related initiatives focus
examples of programs and policy areas that impact health in
on enforcing animal and plant embargoes and improving public
the various departments.
health system’s readiness against a bioterrorism attack.
Department of Agriculture (USDA): Through departments
Department of Justice (DOJ): Bureau of Alcohol, To-
such as the Center for Nutrition Policy and Promotion,
bacco, Firearms, and Explosives ((ATF), formerly housed
the Food Safety and Inspection Service, the Animal and
in Treasury), oversees initiatives designed to protect the public
Plant Health Inspection Service, and the Animal Research
from health risks posed by illegal distribution and sales of alco-
Service, the USDA is involved in a range of health-related ini-
hol, tobacco, and firearms.
tiatives. These include ensuring the safety of meat, poultry, and
Department of Labor: Occupational Safety and
egg products; tracking the impact of infectious diseases on U.S.
Health Administration (OSHA) and the Mine Safety
livestock and poultry; promoting healthy food and nutrition ini-
and Health Administration (MSHA) promote standards
tiatives, and overseeing practices to provide safe drinking
and regulations to protect the health and safety of workers
water to rural America. USDA administers the School Meal
in the U.S.
Program and partners with HHS to determine the Dietary
Guidelines for Americans.
Department of Transportation (DOT): the National
Highway Traffic Safety Administration (NHTSA) pro-
Department of Defense (DOD): Administers major health
motes vehicle safety and healthy behavior on U.S. highways
care and prevention programs, runs BSL-4 lab, and funds
through public health-related practices such as anti-drunk
research for various diseases through such divisions and
driving initiatives and seat belt laws.
initiatives as the U.S. Army Medical Research Institute of
Infectious Diseases, the Armed Services Blood Program
Department of the Treasury (Treasury): Promotes the
Office, and the Global Emerging Infections Surveillance
compliance of alcohol and tobacco product manufacturing,
and Response System.
marketing and importation with federal laws, and oversees the
collection and levying of related taxes through the Alcohol
Department of Education (ED): the Office of Safe and
and Tobacco Tax and Trade Bureau.
Drug-Free Schools (OSDFS) oversees physical education,
mental health, drug education, and anti-violence campaigns
Department of Veterans Affairs (VA): VA offers public
designed to promote national student health and a safe
health and medical services (including offering veterans health
school-going experience.
benefits), engages in collaborative medical and health re-
search, and is on-call for mobilization duties in the advent of
Department of Energy (DOE): the Office of Environmental
emergencies and disasters.
Management ensures the safe handling of waste generated by
energy production, tests soil, air, and water near energy sites,
Environmental Protection Agency (EPA): Sets and
and supports epidemiological research on the health effects of
enforces standards for air and water quality, pesticide use,
radiation exposure.
waste and recycling, and chemical use and researches and
partners with local and state agencies to assess environmental
Department of Homeland Security (DHS): Through
impact of disease.
divisions such as Border and Transportation Security and
Independent Establishments and Government Corporations
Consumer Product Safety Commission (CPSC): Oversees
on cigarette and smokeless tobacco labeling, advertising, and
consumer product safety initiatives (looking after common
promotion.
health hazards such as toys, cribs, power tools, cigarette
Nuclear Regulatory Commission (NRC): Regulates usage
lighters, and household chemicals).
of nuclear materials. Works in conjunction with environmental
Federal Trade Commission (FTC): Enforces federal truth-
and public health professionals to plan for and respond to
in-advertising laws on claims for weight-loss advertising, foods,
potential nuclear emergencies (such as Three Mile Island).
drugs, dietary supplements, and other products promising
President’s Commission on Physical Fitness: Advises the
health benefits. Monitors unfair practices on deceptive claims
President through the Secretary of Health and Human Services
for tobacco and alcohol advertising and reports to Congress
about physical activity, fitness, and sports in America.
24
C. ACCOUNTABILITY FOR A HEALTHIER AMERICA
A strong public health system focused on the
demia, and public health organizations and
prevention of disease and injury is essential
asked them to make recommendations for im-
to protecting the health and safety of all
proving accountability throughout the public
Americans. But today, our public health sys-
health system. Their top recommendations
tem is not held as accountable as it should be
are:
for health outcomes, or for how taxpayers’
I Link accountability to measurable im-
public health dollars are spent.
provements in the health of communities;
Americans across the country deserve and
I Create policies, incentives, and other mech-
should expect basic health protections.
anisms that will encourage accountability and
However, right now, fundamental public
continuous quality improvement (CQI); and
health services intended to protect our
health and the funding of these programs
I Expand accreditation for public health
often differ dramatically from state to state
systems to support accountability.
and among communities within states.
The following are a range of actions the fed-
Currently, there is no systematic approach in
eral government could take to improve ac-
the U.S. for ensuring minimum levels of
countability and support efforts to create a
health services for all Americans, or that gov-
CQI mechanism to ensure that public health
ernment funding is being spent on public
programs keep pace with the changing needs
health programs in the most effective way.
of communities. For accountability efforts to
Establishing standards and accountability ef-
be successful, the federal government must
forts have often been limited by lack of suffi-
provide strong leadership, state and local
cient resources and other incentives to
governments must be given adequate re-
change existing systems.
sources and be empowered to make changes,
and officials must build on existing account-
Trust for America’s Health (TFAH) convened
ability and accreditation programs.
a number of experts from government, aca-
Recommendations for Improving Accountability
The federal government should:
porates performance measures tied to im-
I Create a pilot program to give state and
proved health outcomes. This program
local health departments greater flexibility
would reward, incentivize, and equip states
with the use of prevention and preparedness
and localities that are committed to ac-
funds in exchange for more accountability
countability for improving health outcomes
for improving health in communities. The
and could be applied more broadly to im-
U.S. Centers for Disease Control and Pre-
prove prevention initiatives for the entire
vention (CDC) should establish a pilot pro-
public health system.
gram where state and local health
I Create a funding stream to help state and
departments would be allowed greater flex-
local health departments pay for accounta-
ibility for how they use federal funds in ex-
bility capacity development. Many state
change for greater accountability for
and local agencies cannot afford self-assess-
improving health outcomes and measures
ments, preparation for accreditation, and
in communities. This pilot program would
other CQI and accountability efforts.
allow a state or local health department to
Through either a dedicated funding stream
pool its current streams of federal preven-
or a set-aside from existing grants, state and
tion funding and receive additional funding
local health departments should receive
to adopt and implement a locally-generated
federal financial support to improve their
“prevention priority action plan” that incor-
accountability, including use of grant
25
money to finance the work of the Public
ing Memorandums of Understanding out-
Health Accreditation Board (PHAB).
lining clear goals when receiving federal
I
funds. Another approach could be to tie
Create a public health research institute.
Medicaid and other federal health funding
This institute should invest in best practices,
to state and local investment in prevention
generate data on health outcomes and
and to the participation of state and local
workforce issues; address complex problems
agencies in accountability processes, such
like social determinants of health, focus on
as the PHAB’s accreditation program.
prevention, and assist in the development of
accountability measures. Such an institute
I Establish national guidelines and measures
should build on existing partnerships within
for core public health functions and require
the federal government, as well as consider
that states and localities report the findings
efforts going on in state and local govern-
to the public and federal government. In
ment and the private sector.
exchange for federal funding to support
I
such functions, health departments should
Encourage governors, mayors, and other
demonstrate that they have met minimum
locally elected officials to become more di-
accountability standards. The guidelines
rectly accountable. Promoting the health
should move beyond process to focus on
of a community goes beyond just what
quantitative objectives and outcomes to help
health departments do. Even though
ensure institutional capacity to meet core
much of the federal funding for health
functions and high-priority services. The
passes through health departments, it is im-
federal government would compile, analyze,
portant that elected officials commit to any
and report on these measures to policy-
accountability process, including engaging
makers and the public on a regular basis.
all relevant government agencies and sign-
CHALLENGES FOR BASING ACCOUNTABILITY ON IMPROVING
HEALTH OUTCOMES
There are a number of challenges for establishing health outcome standards or measures,
including:
I It can take a significant period of time before many interventions have a significant effect on health;
I There are not always evidence-based interventions with demonstrated links to change in health
(for example, available data may only show an impact on behaviors that affect health); and
I Data collection and surveillance systems may not exist to measure the desired change in health.
Accountability efforts should strike an appropriate balance between intermediate process
measures and longer term health outcome goals until both the research base and data points
are available to shift primarily to an outcomes approach.
Logic models that set particular milestones can be established to measure intermediate goals.
A two-way system of accountability should be created, where the federal government and
state and local governments all share responsibility. The federal government as a grantor
should work with state and local government grantees to determine mutually agreeable goals
and work together to assess achievement. This process must also incorporate mechanisms for
revising goals and measures based on progress and new scientific developments.
26
Current State Efforts to Foster Accountability and
Quality Improvement
Many states have been implementing initiatives to foster accountability and quality im-
provement. The most successful examples of these efforts have been when local health
departments have actively collaborated with state health departments in the design and
implementation of state-wide programs.24 Some state examples include:
I North Carolina, with strong local support, has made accreditation mandatory for local health
departments.25 As of July 2008, 40 (out of 85) local health agencies have been accredited.26
I In Washington, the legislature mandated the development of a “public health improve-
ment plan” with a strong evaluation component that moves in the direction of linking
performance assessment of local public health departments with health outcomes.27
I Illinois recently issued a State Health Improvement Plan that implements the legislature’s
mandate to build prevention and accountability into the state’s health system.28 It does
this by identifying four specific health conditions:1) alcohol, tobacco, and other drug use;
2) obesity; 3) physical activity; and 4) violence, of which reduction is central to prevention,
and identifying specific interventions to reduce them.
Current Federal Efforts to Foster Accountability and
Quality Improvement
CDC is working to support accountability and quality improvement in targeted areas.
For example:
I The Racial and Ethnic Approaches to Community Health (REACH) program, which
funds national and regional centers of excellence and community-level programs, pro-
motes evidence-based approaches to reducing disparities in health outcomes among
racial and ethnic groups.
Current Accreditation Efforts
With support from CDC and the Robert Wood Johnson Foundation, leaders of major na-
tional public health organizations formed the Public Health Accreditation Board (PHAB) in
May 2007. The mission of the PHAB is to implement a voluntary national accreditation
program for state and local health departments.29 This program focuses on continuous
quality improvement (CQI) in health departments and involves a neutral, external assess-
ment of conformity with the standards required for accreditation in order to bolster
“health department accountability to the public and policymakers.”
The PHAB plans to issue proposed standards for accreditation in 2008.30 Accreditation
programs and accountability efforts should establish a balance between “intermediate”
outcomes, such as the implementation of a specific preventive service or intervention for
which solid data show a link to improved health outcomes, and actual health outcomes,
such as Body Mass Index (BMI) measurement. Success in delivering “intermediate out-
comes” can serve as a surrogate marker of effectiveness in achieving the ultimate health
outcome and as a meaningful measure of improved performance and accountability for
health departments. See www.phaboard.org for more details.
27
KEY ELEMENTS OF A NEW HEALTH OUTCOMES ACCOUNTABILITY
PILOT PROGRAM
Eligibility, Selection, and Standards
I CDC would review the plans for technical suf-
I
ficiency and compliance with federal criteria
CDC, in consultation with states, would es-
but defer to states and localities on priorities.
tablish selection criteria to ensure participa-
tion by a diverse cross section of departments
I The state health departments would imple-
that would most likely benefit from participa-
ment their action plans over a three- year
tion in the program and contribute to lessons
period, with annual reporting to CDC on
that could be applied elsewhere.
progress and issues, which would include
I
the opportunity for a mid-course correction
On the basis of these criteria, CDC would
without loss of funds, and a full evaluation
select up to 10 state health departments
upon completion.
to participate.
I
Funding and Accountability
CDC, in consultation with states and locali-
ties, would set standards for the implemen-
I CDC would provide funding support and
tation of the program, including guidance
other incentives for participation in the
for states on their selection of outcome
demonstration program by:
measures and design of evaluation plans.
L Making grants to support development of
I A Memorandum of Understanding be-
the Prevention Priority Action Plan;
tween the Secretary of HHS and the
L Allowing states the flexibility to merge
state’s governor would be signed in order
their existing federal funds for prevention-
to ensure the delivery of appropriate com-
oriented programs, e.g., diabetes, nutri-
munity-level prevention interventions and
tion, and/or cancer funds, into a single
engage all aspects of state government.
pool to fund state and local priorities in
accordance with their own action plans;
Prevention Priority Action Plans
L Providing a significant increase over the
I Each state would develop a “prevention
state’s current federal prevention funding;
priority action plan” through an inclusive
L Permitting a portion of grants to be used
public process with review by CDC.
for funding infrastructure improvements
I With national prevention goals and priori-
needed to support implementation of ap-
ties as a guide, the plans would outline the
proved plans; and
high-priority prevention goals of the state,
L Funding the evaluation.
strategies and programs for achieving
them, and quantitative performance meas-
I At the conclusion of the three-year demon-
ures tied to health outcomes. These
stration period, participating departments
could include intermediate measures that
would work with an external partner, such
the state and CDC agree are appropriate
as a local academic institution or research
milestones toward achieving the desired
organization, to evaluate and report publicly
health outcomes.
on any change in health outcomes.
I Priority setting and selection of performance
I Renewal of participation would depend on
measures would draw on such sources as:
the department’s development of credible
L
plans for improving performance in areas
The Healthy People 2010 or 2020 Leading
in which prevention outcome goals have
Health Indicators and Healthy People 2010
not been achieved.
or 2020 goals and supporting evidence;31
L State collected survey or administrative
Evaluation and Expansion
data on key health indicators;
I At the close of the initial demonstration
L
period, CDC, in consultation with states,
The Guide to Community Preventive Services;32
would evaluate the overall results of the
L The Guide to Clinical Preventive Services;33
program, recommend modifications to im-
and
prove its effectiveness, and develop a plan
L Other sources of information document-
for expanding the program so that any
ing the link between specific interventions
qualifying state or locality could participate.
and desired health outcomes.
28
KEY ELEMENTS FOR EXPANDING ACCREDITATION TO
SUPPORT ACCOUNTABILITY
I CDC would have lead responsibility within
Progress reports, audits, site visits, and
the federal government for supporting the
similar requirements associated with
PHAB accreditation program, though some
federal funding impose substantial costs on
of the incentives and support efforts might
state and local heath departments. Easing
be implemented by other elements of HHS.
these requirements would provide a
I
positive incentive and reward for achieving
CDC should establish a coordination
accreditation.
mechanism for ongoing consultation and
collaboration with the PHAB.
L Creating a two-tiered special infrastructure
I
grant fund that would support filling gaps
CDC should develop incentives and pro-
necessary to achieve accreditation and sus-
vide support for states and localities to
taining ongoing infrastructure necessary to
pursue accreditation. Examples of incen-
support accreditation and CQI. Accredita-
tives and support include:
tion is not a one-time event but rather an
L Providing grants to states and localities to
ongoing process aimed at continuous qual-
support their pursuit of accreditation.
ity improvement. A two-tiered special in-
Preparation for and pursuit of accredita-
frastructure trust fund would provide a
tion imposes costs on state and local
further incentive to pursue accreditation,
health departments that can deter partici-
support CQI, and reflect the fact that ac-
pation in a voluntary program. CDC
credited agencies have a solid framework
should develop and implement a grant
for making good use of federal dollars.
program to cover a share of these costs.
I CDC would require a significant increase in
Additionally, states and localities should be
resources both to manage its federal lead-
allowed to target a portion of existing
ership role on accreditation and to fund
funds and grant money to accreditation
PHAB and health department activities di-
processes, for instance, funds from the
rectly related to achieving accreditation.
Preventive Health and Health Services
Block Grant should be able to be used for
I The special infrastructure grant fund, which
supporting accreditation processes.
presumably would be implemented by
L
CDC’s National Center for Chronic Disease
Easing CDC reporting requirements and other
Prevention and Health Promotion in con-
federally-imposed administrative burdens on
junction with the prevention block grant,
departments that achieve accreditation.
would require its own dedicated resources.
29
D. WORKFORCE CRISIS FOR PUBLIC HEALTH:
RECRUITING THE NEXT GENERATION OF
PUBLIC HEALTH PROFESSIONALS
From first responders to scientists
I Preventing or containing potential infec-
searching for cures to disease, our public
tious disease outbreaks such as pandemic
health workforce is vital to protecting our
flu, Methicillin-resistant Staphylococcus au-
nation’s health. But our public health
reus (MRSA), and antibiotic-resistant bugs;
workforce is in crisis. There is a serious
I Responding to natural disasters like Hur-
deficit of public health workers with the
ricanes Ike, Gustav, and Katrina to poten-
expertise needed to meet the depth and
tial bioterrorism attacks;
breadth of the responsibilities they are
I Reducing chronic diseases, including can-
expected to carry out.
cer, heart disease, type 2 diabetes, and
Public health professionals are responsible
Alzheimer’s;
for keeping America healthy and preventing
I Preventing disease threats to our food, air,
disease. In today’s dangerous world, they
and water; and
also help keep our nation secure. Examples
I Limiting accidents, injuries, and occupa-
of their many responsibilities include:
tional hazards.
Workforce in Crisis
There is a shortage of public health workers --
partment workers will be eligible to retire
and the problem is expected to get worse. As
within just two years.36
baby boomers retire, there is not a new gener-
I Eleven percent of state public health posi-
ation of workers being trained to fill the void
tions are currently vacant,37 and four out
of expertly-trained public health workers our
of five current public health workers have
country needs. If the crisis is not addressed
not had formal training for their specific
now, these vacancies leave the public at unnec-
job functions.38
essary risk for preventable health problems.
I
I
The Public Health Service Act, which in-
The U.S. has an estimated 50,000 fewer pub-
cludes provisions for training, recruit-
lic health workers than it did 20 years ago.34
ment, and retention of public health
I One-third of the public health workforce
professionals, has not been reauthorized
in states will be eligible to retire within five
in 10 years and is outdated.
years,35 and 20 percent of local health de-
It’s Time for Action
To ensure the health and safety of Ameri-
ficient. New policies and incentives must be
cans, federal, state, and local governments
created to make public service careers in
must take action now to recruit, train, and re-
public health an attractive professional path,
tain the next generation of professionals in
especially for the emerging workforce and
public health. Existing efforts to recruit and
those changing careers.
retain the public health workforce are insuf-
30
The next Administration and Congress should:
I Institute a grant and/or loan repayment
a “Ready Reserve,” and establishing a ded-
program to college juniors and seniors and
icated funding stream for all Corps activi-
graduate students (in their final years of
ties under the management and fiscal
training) who commit to entering govern-
control of the Surgeon General.
mental public health. Students would have
I Task a new public health institute or an ap-
to meet certain academic requirements,
propriate HHS office with collecting and
such as achieving a B average, to qualify
disseminating best practices and providing
for the program.
information about career categories, skill
I Provide federal matching funds to state
sets, and workforce gaps. An enumeration
and local governments to invest in recruit-
of the public health workforce is also
ment, retention, training, and retraining
needed to determine the current distribu-
for public health workers.
tion of jobs to include trend lines, as well
as wages, benefits, training, and pathways
I Allow federal funding to support more pub-
from which workers enter public health.
lic health education programs. Currently,
only the nation’s 40 schools of public health
I Create an interagency advisory panel to co-
can compete for certain CDC and other
ordinate workforce development at all lev-
funding to support governmental public
els of government. Such a panel would
health professionals. Universities that offer
serve as a clearinghouse that would help
master’s programs in public health (outside
link federal, state, and local public health
the schools of public health) and other re-
workforce development; coordinate re-
lated master’s programs should be allowed
cruiting and training efforts; and provide
to compete for funding.
technical assistance to expand the public
health workforce. The panel should be
I Strengthen the U.S. Public Health Service
replicated at the state level as well.
Commissioned Corps by increasing the
number of active duty personnel, creating
The federal government should partner with state and local governments to:
I Establish a national public health retire-
gram created specifically for them, such as
ment system for state and local workers.
through an entity like TIAA-CREF.
Government salaries are often less com-
I Identify candidates for careers in public
petitive and do not have portable retire-
health at community colleges, vocational and
ment benefits. This makes it difficult for
technical education programs, One Stop Ca-
public health workers to change jobs and
reer Centers, and Job Corps Centers.
advance their careers. A new system
should be established that would allow
I Require public health representation on
public health professionals to buy into the
state, local, or regional workforce boards
Federal Employees Retirement System, the
to help expand career recruitment in the
Public Health Service Commissioned
public and private health sectors.
Corps retirement program, or a new pro-
31
Workforce Issues In-Depth
SPECIAL CHALLENGES FOR EDUCATING AND TRAINING PUBLIC
HEALTH PROFESSIONALS
Recruiting, training, and retaining the public
Eighty percent of public health professionals
health workforce are complicated because
have not received training in the area of their
the types of needed public health expertise
specific duties.40
vary widely.
There are 40 graduate schools of public
There is no one typical career path for “pub-
health and an additional 70 institutions offer
lic health.” The field encompasses a range of
masters programs in public health. Increas-
specialties and services. This means the edu-
ingly, these schools are not educating stu-
cational track is not as clear cut as it is for
dents for the scope of available governmental
many other professions.
public health positions. Only 20 percent of
graduates who receive master’s degrees
The Institute of Medicine (IOM) points out
from schools of public health go on to work
that public health professionals “receive their
in governmental public health.41
education and training in a wide range of disci-
plines and in diverse academic settings, includ-
Currently, only the 40 graduate schools of
ing schools of public health, medicine, nursing,
public health are eligible for funding streams
dentistry, social work, allied health professions,
from the CDC, while the 70 public health
pharmacy, law, public administration, veteri-
masters programs and other graduate pro-
nary medicine, engineering, environmental sci-
grams, such as public health nursing, are not
ences, biology, microbiology, and journalism.”39
eligible for these funds.
PUBLIC HEALTH SERVICE COMMISSIONED CORPS BACKGROUND
The Public Health Service Commissioned
L Routinely, an estimated 25 percent of new
Corps is the backbone of the public health
Corps members transitioned into their
workforce for federal agencies. The Corps
positions after serving in the armed
reports to the Surgeon General and consists
forces.44 Former armed services
of 11 categories of public health professionals,
members may lose their rank if they do
including physicians, environmental health
not enter the Corps through an inter-
experts, nurses, veterinarians, pharmacists,
service transfer. Because of the cap on
and mental health professionals.
Corps members, inter-service transfers
have become rare.
There are concerns with the existing structure
of the Corps that limit the effectiveness of the
L New hires to the Corps typically begin as
Corps and the attractiveness of the Corps as a
reservists, and it often takes years to
career option:
become an active service member
L
because of the cap mentioned above.
There is a Congressionally-mandated cap of
2,800 active duty members of the Corps,
L Salaries for Corps members and reservists
which has been in place since 1993.42
are paid by the federal agencies where
There are 3,200 reservists, who fill many of
they work; there is no direct or dedicated
the same positions as the active duty mem-
funding for the Corps.
bers, and 3,000 inactive or retired mem-
(Note: Information about Commission Corps is
bers that are not part of the “active”
also included on page 22.)
Corps.43 Reservists are less likely to receive
promotions and have less job protection
during forced reductions.
32
Establishing First Responder Teams
The President’s Fiscal Year 2008 budget included a proposal for Health and Medical Response
Teams (HAMR), but the program was not funded. The idea is to create special teams to
organize, train, and equip public health personnel to improve the nation’s capabilities for
responding to health emergencies. When the teams were not responding to crises, they
could be used to supplement state and local health departments that are facing severe
ongoing workforce shortages. This would help provide an interim solution to the state and
local workforce shortage crisis.
Creating a “Ready Reserve”
There are not sufficient numbers of public health professionals to respond during major
health emergencies, and when Corps members are called away to respond to
emergencies, it means their ongoing functions are often neglected. If a “Ready Reserve”
program was created, retired members of the Corps could become reservists who could
be deployed on short notice during emergencies, or could fill in at federal agencies when
active members are needed during emergencies, to ensure ongoing functions are carried
out. Reservists would be required to participate in an appropriate number of drills and
training throughout the year. Members of the reserve could also help fill in to provide
services for underserved communities where health problems are the greatest.
Recruiting Retirees to Train the Next Generation
In addition to other workforce shortages, a large number of current educators and academics
focused on training health professionals are expected to retire in the near future. To help fill
the gap, retired Corps members should be given incentives to move into faculty positions to
help train the next generation of public health professionals. This could be modeled on
similar efforts, like the “Troops to Teachers” program.
MODELS FOR CREATING A NEW ENTITY TO RESEARCH AND SUPPORT
THE PUBLIC HEALTH FIELD
Currently, there is no agency or entity that
Models for where this function could be cre-
studies and disseminates best practices and in-
ated and housed could be within a new Public
formation about career categories, skill sets,
Health Research Institute or within the Office
and workforce gaps in public health. This
of the Surgeon General, an Undersecretary
should include examining public health func-
for Health, or other offices at HHS. All data
tions and jobs throughout the federal govern-
should be collected in conjunction with the
ment beyond health agencies, and public health
U.S. Department of Labor and Bureau of
functions within state and local governments.
Labor Statistics.
33
SPOTLIGHT ON SPECIAL STRATEGIES FOR RECRUITING
AND RETENTION
Area Health Education Centers and the Youth Health Service Corps
Area Health Education Centers (AHEC) are federally funded and link university health science
centers with community health delivery systems to provide training sites for students, faculty,
and practitioners. A few states, such as Connecticut, have used some of their AHEC funds to
establish Youth Health Service Corps initiatives that train and place high school students as
volunteers in community health agencies. The student volunteers, who may be enrolled in
vocational and technical education, not only provide relief to the workforce shortage prob-
lem, but may also help develop a pipeline for future public health employees. Under the
Youth Health Service Corps model, an AHEC may partner not only with health entities, but
also programs such as Learn and Serve America, a part of the Corporation for National and
Community Service.
Establishing Programs at Community Colleges and Vocational and
Technical Programs
I Nearly 40 percent of community college attendees are first generation college students,
and many are non-traditional students.45
I Tech Prep programs serve secondary and higher education institutions. They offer two-
year associate programs, and two-year certificates.
I Job Corps is an education and vocational training program administered by the U.S. De-
partment of Labor.
Building public health curricula and courses at community colleges and vocational and
technical programs could provide new streams for recruiting and training a new
generation of public health workers. Community colleges typically have greater flexibility
in establishing new and tailored course offerings and could partner with public health
departments to set up training to address the unique needs of the communities they
serve. Vocational and technical education centers, and health focused career academies,
should also create apprenticeships with health departments. These types of initiatives will
help expand and diversify the public health workforce.
Career-Ladder Programs to Support Mid-Career Training
As employers, the federal, state, and local government health agencies should support and
fund ongoing professional development training for public health workers. This will en-
sure that public health workers are prepared to handle the constantly changing public
health needs in communities, skills are kept up-to-date, and opportunities are provided for
career advancement.
34
PUBLIC HEALTH WORKFORCE OVERVIEW
There are approximately 3,000 federal, state,
other agencies ranging from the Bureau of
and local government health agencies in the
Prisons to the Department of Homeland
U.S. These agencies often work closely with
Security (DHS).
private sector health associations.
I There are more than 100,000 state public
I The Public Health Service Commissioned
health employees, and approximately
Corps is the nucleus of the federal govern-
160,000 local public health employees.46, 47
ment’s public health workforce.
I Public health nurses constitute 25 percent
I The main federal public health agencies in-
of the public health workforce in states.48
clude the U.S. Centers for Disease Con-
I There are 2,800 veterinarians who are part
trol and Prevention (CDC), the Office of
of the government public health workforce.
the Surgeon General, the Substance Abuse
They work on food safety, emergency pre-
and Mental Health Services Administration
paredness, detecting disease outbreaks,
(SAMHSA), the Health Resources and
and controlling emerging new disease
Services Administration (HRSA), and the
threats.49 For instance, veterinarians were
Food and Drug Administration (FDA).
the first to identify West Nile Virus.
There are public health functions in many
EXISTING EFFORTS TO RECRUIT AND RETAIN THE PUBLIC HEALTH
WORKFORCE ARE INSUFFICIENT
I HRSA has a number of programs aimed at
student loan repayment demonstration
recruiting health professionals for
project at the U.S. Department of Health
underserved areas. Most of these focus
and Human Services (HHS) to encourage
on staff for Community Health Centers
service in state public health departments,
and other primary care settings.
but the program has not been funded.
I Some CDC programs may indirectly
I The Public Health Preparedness Workforce
address workforce issues, such as
Development Act was introduced by
Prevention Research Centers, the Centers
Senators Richard Durbin (D-IL) and Charles
for Health Preparedness Program, and
Hagel (R-NE) and Rep. Doris Matsui (D-CA)
bioterrorism preparedness funding, but
to establish public health workforce
workforce recruitment and retention is
scholarships and loan repayment programs,
only a minor part of these efforts.
specifically aimed at increasing the
I
emergency public health workforce, but the
The 2006 Pandemic and All Hazards
legislation has not been passed by Congress.
Preparedness Act (PAPHA) created a
35
E. INCORPORATING PUBLIC HEALTH AND
PREVENTION INTO HEALTH CARE REFORM
America must provide quality, affordable
tion of disease and injury should be a cor-
health care to all. A strong public health sys-
nerstone of a health reform plan.
tem and public policies focused on preven-
As part of health care reform, the federal government and Congress should:
I Provide universal, quality coverage and ac-
year in effective programs to improve
cess to give all Americans the opportunity
physical activity, good nutrition, and pre-
to be as healthy as they can be. All indi-
vent smoking could result in savings of
viduals and families should have a high
more than $16 billion in health care
level of services that protect, promote, and
costs annually within five years. This is a
preserve their health, regardless of who
return of $5.60 for every $1 spent.
they are or where they live. Coverage
L Many clinical preventive interventions
alone is insufficient. A reformed system
require a strong community-level base to
must also ensure access to care. Every
be effective. Community programs sup-
American should have a “medical home”
port the ability of individuals to follow
so they have access to coordinated care.
medical advice and make healthy
State and local health departments often
choices. For example, a doctor can en-
provide direct primary care and/or clini-
courage a person to be more physically
cal preventive services to significant por-
active, including writing a prescription
tions of the population, and therefore,
for a person to get more exercise. How-
need to have adequate funding streams if
ever, unless a person has access to a safe,
that role continues in a reformed system.
accessible place to engage in activity, they
I Invest in disease prevention to ensure that
will not be able to “fill” this prescription.
universal coverage is as cost-effective as
I Ensure that any health care financing sys-
possible. A reformed health care system
tem that is developed includes stable and
must invest in both clinical and commu-
reliable funding for core public health
nity-based prevention.
functions and clinical and preventive serv-
L The Partnership for Prevention has
ices. A strong public health system is nec-
identified a series of clinical preventive
essary to help promote better health,
measures that, if fully adopted by 90
monitor the health of the country, and
percent of the population, could save
protect people from health threats that are
100,000 lives a year.
beyond individual control, including
bioterrorism, food-borne illness, and nat-
L Trust for America’s Health (TFAH), in
ural disasters. The nation must adequately
collaboration with The New York Acad-
fund federal, state, and local public health
emy of Medicine, has identified a series
departments and programs to be able to
of community level disease prevention
fulfill their responsibility of protecting the
programs for improving rates of physical
public’s health, and, at the same time, pub-
activity, nutrition, and smoking cessation
lic health needs a predictable, sustainable
that could dramatically reduce the preva-
funding stream. Effective implementation
lence and/or severity of the most expen-
of community-level prevention programs
sive chronic diseases in the U.S. today.
requires providing support to community
L Based on an economic model developed
organizations and coalitions that directly
by the Urban Institute, TFAH found that
carry out this lifesaving work.
an investment of $10 per person per
36
I Invest in bolstering the workforce and
vesting in the most effective programs pos-
modernizing information systems for both
sible. Community-based efforts should in-
health care and public health needs; if the
clude performance measures and
public health system is not adequately sup-
independent assessments to be able to un-
ported, it will undermine the successes of
derstand cost-effectiveness and impact on
health care reform efforts. The public
health to better inform where to best in-
health system is facing a critical workforce
vest resources.
shortage. Bolstering the public health
I Ensure that a reformed health care system
workforce must be included in efforts to
will be prepared to react to and mitigate
fortify the nation’s overall workforce of
the consequences of a public health emer-
health professionals. Electronic health
gency. A reformed health care system
records (EHRs) contain invaluable infor-
must contribute to critical public health
mation about the health of Americans.
functions, such as:
While individual privacy must be vigilantly
protected, aggregate information about
L Surveillance, including integrating into
the health of communities would provide
other electronic health systems the mech-
public health officials with unprecedented
anisms that identify new or urgent crises;
levels of information to investigate health
L Surge capacity by providing ongoing fi-
threats, such as being able to look for pat-
nancial support for health facilities to
terns of disease and connecting this infor-
build the capacity to manage a sudden
mation to possible causes. Public health
increase in demand;
officials should have access to EHRs for
community-based research purposes while
L Appropriate reimbursement for pre-
individual privacy is protected.
paredness and response so providers
have the financial incentive and capac-
I Extend quality assurance to community-
ity to respond; and
based prevention in addition to direct
medical care. Since community-based pre-
L Community resilience by supporting ef-
vention programs are important to main-
forts to create stronger community ties
taining the health of Americans, every
between the reformed health care sys-
effort should be made to ensure we are in-
tem and communities.
37
F. MEDICARE: IMPROVING PREVENTION TO HELP
CONTAIN COSTS AND IMPROVE HEALTH
By the time they are eligible, millions of Amer-
are projected to increase the country’s health
icans enter Medicare with health conditions
care costs by 25 percent during this time pe-
that could have been lessened or prevented.
riod.50 Eighty percent of America’s seniors
In the end, Medicare -- and taxpayers -- bear
live with at least one chronic disease that
the cost burden of providing for people who
could lead to premature death or disability.51
could be significantly healthier or have their
An enhancement of preventive care services
existing conditions much better managed.
- - for people both under and over the age of
65 - - is overdue, as this approach will ulti-
By 2030, 20 percent of the U.S. population --
mately save money and lead Americans down
71 million Americans - - will be 65 or older,
the road to longer, healthier lives.
and Medicare-eligible. Aging-related diseases
Pre-Medicare Prevention: Ensuring Healthy Beneficiaries
Many cases of chronic illness, particularly heart
often makes treatment more effective or
disease, stroke, diabetes, and some forms of
keeps problems from getting worse - all of
cancer, could be avoided or delayed through
which lead to health care cost savings. For in-
physical activity, healthy nutrition, and avoid-
stance, if all seniors were vaccinated for pneu-
ing tobacco use, and through early detections
monia, health care costs could be reduced by
of cancer and other diseases, according to the
$1 billion per year.54 Reducing adult smok-
U.S. Centers for Disease Control and Preven-
ing rates by one percent could result in more
tion (CDC).52 However, most Americans age
than 30,000 fewer heart attacks, 16,000 fewer
without the benefit of strong preventive health
strokes, and health care savings of more than
care or community-based programs that could
$1.5 billion over five years.55
help them stay healthy longer.
Our current health care system is set up in
A recent report by Trust for America’s Health
opposition to the goal of ensuring people
(TFAH) found that if the country invested
reach the age of Medicare as healthy as they
$10 per person per year in proven commu-
can be. Medicare has no legal authority to
nity-based prevention programs, Medicare
help ensure people stay as healthy as possible
could save $5.2 billion annually within five
before they reach 65 years old. The federal
years and nearly $6 billion annually within 10
government should set a national goal of
to 20 years.53 Many clinical prevention serv-
helping Americans stay healthier throughout
ices could also reduce Medicare spending.
their lives - - not only for the savings that
Improving disease screenings and immuniza-
would result from ongoing preventive care --
tions, for example, could help people detect
but so that people live as well and independ-
diseases early or avoid them altogether. This
ently as long as they can.
Medicare Prevention: Optimal Coverage
Seniors currently face significant gaps in cov-
are actually “recommended for the elderly
erage of preventive health care services
population.” A thorough expansion and re-
under Medicare. Physical exams are limited
structuring of Medicare benefits by the Cen-
in scope. Critical screenings and immuniza-
ter for Medicare and Medicaid Services
tions are either offered infrequently or seen
(CMS) will ensure improvements in both the
as “optional” for select beneficiaries, while
span and quality of life of beneficiaries.
only a few of the preventive services covered
38
The federal government should consider potential options for increasing preventive services
within Medicare, including:
I Implement a National Health and Preven-
The set of services would be decided by a
tion Strategy focused on lowering disease
set of experts based on the most effective
rates. This strategy should include every
and highest-impact types of preventive
federal government agency and state and
care, such as breast cancer screenings and
local governments, define clear roles and
pneumonia vaccinations for seniors.
responsibilities, and work with private in-
I Expand Medicare preventive care bene-
dustry and community groups. Develop-
fits. It is important to provide seniors with
ing and implementing policies aimed at
strong preventive benefit care, so they can
reducing obesity and tobacco use should
be as healthy and independent as long as
be key objectives of the strategy.
possible. Currently Medicare prevention
I Create a Healthy Living, Healthy Aging pilot
benefits are limited. Enrollees are offered
program for pre-Medicare-eligible Ameri-
a “Welcome to Medicare” preventive phys-
cans. A pilot program should be devel-
ical exam, which includes height and
oped through Medicare to invest in
weight measures, a blood pressure screen-
proven community-based disease preven-
ing, vision screening, an electrocardio-
tion programs to help prevent disease and
gram, and suggestions for additional
promote better health for Americans
screenings and immunizations such as flu
under the age of 65, potentially focusing
shots, mammograms, and diabetes or can-
on individuals between 55 and 64 years
cer screenings as necessary.56 In addition,
old. This investment would show a return
beneficiaries are eligible for a cardiovas-
in savings for Medicare, since it would re-
cular screening blood test once every five
duce the rates of disease and keep people
years and an additional diabetes screening
healthier as they age. CMS should con-
to be done either once a year for all “at
tract with eight or fewer state or local
risk” beneficiaries or twice a year for those
health departments to support commu-
diagnosed with pre-diabetes.57 Medicare
nity-based anti-smoking, physical activity
also covers 12 other preventive services,
and nutrition initiatives that have demon-
only five of which are “recommended for
strated the capacity to prevent or modify
the elderly population.”58 These services
chronic disease risk factors. Public health
include pneumonia immunizations, hepa-
departments should conduct community
titis B immunizations, Pap smears, mam-
screenings of the targeted population to
mograms, flu immunizations, pelvic
assess healthy behaviors and measure
exams, bone density screenings, colon can-
blood pressure, cholesterol, blood sugar,
cer screenings, diabetes self-management
and other chronic disease risk factors.
trainings, prostate cancer screenings, glau-
coma screenings, and nutritional therapy
I Guarantee proven preventive health care
for diabetes and people with end-state
services to all Americans through a Well-
renal disease. Expanding coverage re-
ness Trust. Medicare funding should also
quires an act of Congress.59
Congress
be used to support a Wellness Trust that
should authorize CMS to expand
will ensure every American has access to a
Medicare preventive benefits based on the
core set of proven preventive care services,
recommendations of the U.S. Preventive
including immunizations and clinical pre-
Services Task Force.
vention, screenings, and health counseling.
39
G. BEHAVIORAL HEALTH: A NECESSARY
COMPONENT OF A HEALTHIER AMERICA
The World Health Organization (WHO) de-
organizations dedicated to ensuring both
fines health as “a state of complete physical,
mind and body are included in the health
mental, and social well-being and not merely
care debate, to outline policy recommenda-
the absence of disease or infirmity.”60 Behav-
tions to develop better federal policies to ad-
ioral health is often considered separately from
dress mental health and substance use
medical or physical health and is not widely
issues.62 The recommendations should be
considered a major public health concern.61
viewed as essential components of the rec-
ommendations in the sections of the Blue-
Trust for America’s Health (TFAH) con-
print for a Healthier America that address
sulted a range of behavioral health experts,
funding, federal structure, accountability,
including members of the Whole Health
and workforce.
Campaign, a collaboration of more than 94
ACCORDING TO THE WHOLE HEALTH CAMPAIGN:
I More than 84 million Americans are
I Mental health problem and addictive
affected by a mental health problems or
disorders account for the third highest
addictive disorder;
loss of workplace productivity among
I
chronic diseases;
Mental health problems and addictive
disorders are the leading cause of
I More than half of all prison and jail inmates
combined death and disability for women
have a mental health problem or addictive
and the second-leading cause for all men;
disorder;
I Mental health problems and addictive
I Fifty percent of students with mental
disorders annually cost the U.S. $171
problems or additive disorders drop out
billion in lost productivity;
of school, the highest rate of any disability
I
group; and
More than 33,000 Americans die by
suicide each year and more than 90
I Americans with serious mental illnesses
percent have a mental health problem or
die -- on average -- 25 years earlier than
addictive disorder;
the general population, mainly due to
untreated health conditions.63
40
Federal Structure
I Behavioral health experts should be rep-
I Leadership is critical to successfully part-
resented on any independent public
nering behavioral and physical health. In
health taskforce or commission that fo-
organizing its new leadership, the U.S. De-
cuses on public health, prevention, and
partment of Health and Human Services
early intervention. Behavioral health ex-
(HHS) should develop and implement a
perts should also be represented within
coordinated effort between behavioral
the staff focusing on public health issues
and physical health. This effort should
in the White House, including within the
occur across all federal agencies that have
Domestic Policy Council.
an interest in health.
I Behavioral health expertise and issues
I Worksite wellness programs for federal
should be integrated into the Office of
employees and their families should in-
Management and Budget (OMB) and con-
clude behavioral health awareness, in-
sidered as an integral part of all health-re-
cluding screening for tobacco use, mental
lated policy, budgetary, and regulatory
health problems, and alcohol use, as well
decisions.
as confidential counseling for people who
have these conditions.
Workforce
I All public health professionals should be
I Academic, as well as continuing, educa-
trained to screen and identify mental
tion settings should cross-train on both
health problems and addictive disorders.
physical and behavioral health.
Accountability
I National measures must be developed to
accountable for meeting goals and creat-
determine how well community-level pre-
ing mechanisms for improvements if goals
ventions and interventions and other gov-
are not met. For example, if a new public
ernment programs are working to improve
health research institute is created, behav-
behavioral health. Once these measures
ioral health must be one of the key areas
are determined, officials should be held
considered.
Funding
I Federal alcohol taxes should be considered
America for more options for funding pub-
as a potential source of revenue for funding
lic health.)
public health programs. These taxes are
I A number of experts have recommended
historically low and are different for beer,
the creation of a Wellness Trust to cover
wine, and liquor. Equalizing federal excise
key clinical and community-based preven-
taxes could raise nearly $8 billion, increas-
tion and intervention services for all
ing public health funding while at the same
Americans. Community-level behavioral
time reducing alcohol-related injuries, sui-
health interventions should be included
cides, and unhealthy alcohol use. (See Sec-
and covered by the Wellness Trust. (See
tion 2A of the Blueprint for a Healthier
Section 2A for additional details.)
41
Section 3
T R U S T F O R A M E R I C A’ S
H E A L T H I N I T I A T I V E
R E C O M M E N D AT I O N S
SECTION
3
SECTION
3
Trust For America’s
Health Initiative
3
S E C T I O N
Recommendations
A. PREVENTION FOR A HEALTHIER AMERICA:
INVESTMENTS IN DISEASE PREVENTION YIELD SIGNIFICANT
SAVINGS, STRONGER COMMUNITIES -- RECOMMENDATION
FOR A NATIONAL HEALTH AND PREVENTION STRATEGY
The nation’s economic future demands we find ways to reduce health
care costs. Preventing sickness is one of the most important ways we
can accomplish this goal. Not only could we save money, but also many more
Americans would have the opportunity to live healthier lives.
Physical activity, nutrition, and smoking are
could result in significant savings in U.S.
three of the most important areas to target
health care costs.
to improve health. A number of commu-
The report concludes that an investment of
nity-based programs have shown they can
$10 per person per year in proven commu-
lead to increased physical activity, good nu-
nity-based programs to increase physical ac-
trition, and smoking prevention, which
tivity, improve nutrition, and prevent smoking
generates significant returns both for
and other tobacco use could save the country
health and financial savings. There is a
more than $16 billion annually within five
wide range of other disease prevention ef-
years. This is a return of $5.60 for every $1.
forts that target these and other health
problems and have a beneficial impact on
Out of the $16 billion, Medicare could save
the health of Americans.
more than $5 billion, Medicaid could save
more than $1.9 billion, and private payers
A National Health and Prevention Strategy
could save more than $9 billion.
and a sustained investment in disease pre-
vention programs could help the country re-
The report focused on disease prevention pro-
alize significant savings. However, we need
grams that do not require medical care and
to make the investment to see the returns.
target communities or at-risk segments of com-
munities. Examples of these programs include
Trust for America’s Health (TFAH) issued a
providing increased access to affordable nu-
report in July 2008 that found that a small
tritious foods, increasing sidewalks and parks
strategic investment in disease prevention
in communities, and raising tobacco tax rates.
43
Estimates for Return on Investment (ROI) for One-Two Years, Five Years,
and 10-20 Years
The economic findings are based on a model
arthritis, and chronic obstructive pulmonary
developed by researchers at the Urban Institute
disease by 2.5 percent within 10 to 20 years.
and a review of evidence-based studies con-
With an investment of $10 per person per
ducted by The New York Academy of Medi-
year in proven community-based disease pre-
cine. The researchers found that many
vention programs, the nation could yield a
effective community-based programs cost less
net savings of:
than $10 per person, and that these prevention
programs have delivered results in lowering
I More than $2.8 billion in one-two years, a
rates of diseases related to lack of physical ac-
return of $0.96, which means the country
tivity, poor nutrition, and tobacco use. The ev-
could recoup nearly $1 over and above the
idence shows that implementing these
cost of the program for every $1 invested;
programs in communities reduce rates of type
I More than $16 billion within five years, an
2 diabetes and high blood pressure by five per-
ROI of $5.60 for every $1; and
cent within two years; reduce heart disease, kid-
ney disease, and stroke by five percent within
I More than $18 billion within 10-20 years,
five years; and reduce some forms of cancer,
an ROI of $6.20 for every $1.
NATIONAL RETURN ON INVESTMENT OF $10 PER PERSON
(Net Savings in 2004 dollars)
1-2 Years
5 Years
10-20 Years
U.S. Total
$2,848,000,000 $16,543,000,000
$18,451,000,000
ROI
0.96:1
5.6:1
6.2:1
Note: When ROI equals 0, the cost of the program pays for itself. When ROI is greater than 0, then the program is
producing savings that exceed the cost of the program.
Savings for Payers
In addition to total dollars saved, the study looked at how this investment could benefit dif-
ferent health care payers.
Net Savings By Medicare, Medicaid, And Private Insurers
For An Investment Of $10 Per Person
1-2 Years
5 Years
10-20 Years
Medicare, U.S. Total
$487,000,000 $5,213,000,000
$5,971,000,000
Medicaid, U.S. Total
$370,000,000 $1,951,000,000
$2,195,000,000
Other payers and
out-of-pocket,
$1,991,000,000
$9,380,000,000 $10,285,000,000
U.S. Total
Conservative Estimates
The savings estimates in the report represent
yield conservative estimates for savings, using
medical cost savings only and do not include
low-end assumptions for the impact of pro-
the significant gains that could be achieved
grams on disease rates and high-end as-
in worker productivity and enhanced quality
sumptions for the costs. The study is based
of life. The researchers built the model to
on 2004 dollars.
44
The federal government should:
I Develop a National Health and Prevention
L Incorporate increased prevention efforts
Strategy that articulates the vision of a
into health care services and finance;
healthier America: The U.S. Secretary of
L Strengthen collaboration among public
Health and Human Services (HHS), on
agencies and the private sector; and
behalf of the President, should be charged
with developing a strategy through a col-
L Ensure essential prevention services are
laborative process. The strategy must:
delivered nationwide in accordance with
minimum national standards.
A NATIONAL HEALTH AND PREVENTION STRATEGY SHOULD
INCLUDE AS CORE OPERATING PRINCIPLES:
I Efficient deployment of resources to prevent illness;
I Accountability for outcomes;
I Recognition that helping people be healthy requires addressing the entire social context, in-
cluding geographic, economic, racial, and ethnic disparities; and
I Performance standards, outcome measures, and accreditation procedures for delivery of es-
sential prevention services by federal, state, and local agencies.
A National Strategy to Combat Obesity should be a central component of a National Health and
Prevention Strategy. (See Section 3B for more details on a National Strategy to Combat Obesity.)
45
The following analysis is based on a national research project
ease and stay healthy will save money on long-term health
funded by TFAH and conducted by Greenberg Quinlan Rosner Re-
care costs, against just 32 percent who believe that this type
search and Public Opinion Strategies. The project included eight
of investment is not worth the cost.
focus groups conducted in May 2008 among various audiences in
I Health issues have a real place in the debate. Though it is
four locations, as well as a national survey of 1,026 registered
unlikely major diseases and health problems like obesity trump
voters conducted June 1-8, 2008. The margin of error is +/- 3.1
the economy as a high priority for Americans, these health is-
percentage points at the 95 percent confidence level.
sues are certainly very real for many people. As demonstrated
I Investment in keeping people healthy and preventing
by the table below, nearly as many people (44 percent) believe
disease is viewed as an effective measure for keeping
that the U.S. needs to make an immediate investment in health
health care costs down. As the table below shows, 63
issues as believe that while these health issues are important,
percent believe that investing in helping people prevent dis-
the economy is a bigger concern (47 percent).
Investment in Health Issues Seen as Important Priorities
Respondents were asked “Now let me read you some short statements about health problems and safety issues in the United States. Please tell me
which statement comes closer to your own view.”
1st Statement - 2nd Statement
Investing in helping people prevent disease and stay healthier now will save money on health care
costs in the long run.
63 - 32
Investing in helping people prevent disease and stay healthier now will not help, because it will cost
too much and too many people will continue to make poor health decisions anyway.
Diseases and major health issues such as childhood obesity are big problems, and we need to
invest more money now into preventing them.
44 - 47
Diseases and major health issues present real problems for the country, but there are too many
other priorities, such as education or the economy, that we need to invest in first.
Prevention is seen as a top reason to increase government
ments centered on prevention are convincing reasons to invest
funding for health issues. As seen in the table below, nearly
more government funding into health issues.
three-quarters or more of the American public believe that state-
Top Reasons to Increase Health Funding Center on Prevention
Respondents were asked “Please tell me whether this is a very convincing, somewhat convincing, a little convincing or not at all convincing reason to
increase government funding for health issues, like researching and preventing major diseases and health problems.”
Very Convincing
Total Convincing
America’s future depends upon the health of our children, yet our kids are becoming less healthy every
day, falling behind the rest of the world, and could be the first generation to live shorter, less healthy lives
45
74
than their parents. We are failing our children, and it is time to make their health our top priority.
There is a clear connection between people’s living environment and their health -- we need to make
sure our communities are clean, healthy, and safe. When we invest in improving the health of our
43
78
communities, we improve the health of the people who live and work there.
Major diseases and health problems are driving health care costs through the roof and bankrupting
American businesses. If we invest now in preventing disease and staying healthy, people will have
fewer illnesses and their health care costs will be lower, and families and businesses will have to
39
73
spend less on health insurance and medical care, which will save us all money in the long run.
Prevention-centric solutions to the problem are seen as
The top ideas for combating obesity centered on increasing
useful. When given a list of 13 potential preventive measures
physical activity and improving nutrition for children in
to help combat America’s obesity epidemic, at least 60 per-
schools. Tax incentives for staying healthy and expanded nu-
cent of the public viewed 11 of the measures as useful ideas.
tritional labeling in stores and restaurants also scored well.
46
B. F AS IN FAT: HOW OBESITY POLICIES ARE FAILING
IN AMERICA -- RECOMMENDATIONS FOR A NATIONAL
STRATEGY TO COMBAT OBESITY
Obesity is a public health crisis in America.
As part of a larger National Health and Pre-
America’s future depends on the health of its
vention Strategy, Trust for America’s Health
citizens. The obesity epidemic has lowered
(TFAH) recommends the country create a
productivity and put a major strain on the na-
National Strategy to Combat Obesity - - a
tion’s health care system. More than one
comprehensive, plan that involves govern-
quarter of health care costs are now directly
ments at all levels, researchers, communities,
related to obesity and physical inactivity. In
faith-based organizations, schools, families
just the past two decades, adult obesity rates
and individuals, employers, insurers, the
have climbed from 15 percent to 30 per-
food and beverage industries, and agribusi-
cent.64 Today, two-thirds of adults are obese
ness and farmers. The following are some of
or overweight. Even more alarming is the
the major recommendations that the federal
number of children who are at risk. With ap-
government should take for developing a Na-
proximately 23 million children overweight
tional Strategy to Combat Obesity.
or obese, today’s generation of young people
may be the first in American history to lead
sicker, shorter lives than their parents.
The Federal Government Must Lead and Work with Every Segment of Society
Individuals have the responsibility to eat
tle time for preparing healthy meals or exer-
properly and be physically active. But, gov-
cise. With greater distances between home,
ernment has an important role to play as well.
work, school, and shopping areas Americans
It can remove the obstacles that make it hard
are eating out more frequently and relying
for individuals to make healthy choices.
more on prepared foods. Government has
the responsibility to help individuals deal with
Many of the forces that have contributed to
the forces that are beyond their control. Gov-
the obesity crisis are deeply ingrained in our
ernment must lead, and work with every seg-
culture. Nutritious foods often cost more,
ment of society to develop solutions.
and the pressures of work and family leave lit-
The next President should:
I Make obesity a national health priority and
I Establish a National Obesity Prevention Ad-
work with Congress to put substantial re-
visory Board made up of representatives
sources behind a National Strategy to
from state and local government, health
Combat Obesity;
care, business, the food and beverage indus-
I
try, education, civic and faith-based commu-
Convene a sub-Cabinet working group to
nities, farmers and researchers to consult
develop a government-wide approach to
with the sub-Cabinet working group; and
addressing obesity;
I Launch a nationwide public education cam-
paign on obesity.
47
Federal Agency Action
I Each federal agency should review its exist-
cies at the U.S. Department of Transporta-
ing programs, budgets, and new initiatives
tion (DOT), U.S. Department of Housing
to examine the direct and indirect impact
and Urban Development (HUD), U.S. En-
of these initiatives on obesity. Policies and
vironmental Protection Agency (EPA), and
programs in nearly every federal agency
U.S. Department of the Interior (DOI).
have an impact on obesity, ranging from
Upon completing the review, each agency
farm subsidies at the U.S. Department of
should propose ways it can help support a
Agriculture (USDA) to smart growth poli-
National Strategy to Combat Obesity.
The Federal Government and Schools
The USDA should issue revised school nutri-
foods recommended in the most recent Di-
tion guidelines based on expected recom-
etary Guidelines for Americans. The U.S.
mendations from the Institute of Medicine
Department of Education should set na-
(IOM) to be implemented as soon as possi-
tional standards for physical education and
ble to ensure that schoolchildren consume
physical activity in the schools.
The Federal Government and Business
The federal government should lead by ex-
updating and increasing obesity-related cov-
ample and provide comprehensive health
erage and reimbursement for preventive
care benefits for addressing obesity through
services such as nutrition counseling and
the Federal Employee Health Benefits Pro-
physical activity programming. Government
gram. Medicare, Medicaid, and the State
at every level should provide incentives to
Children’s Health Insurance Program
employers to offer workplace wellness and
should set an example for private insurers by
prevention programs to their employees.
The Federal Government and the Food and Beverage Industries
The federal government should encourage
support nutrition labeling and to ensure that
food, beverage, and confectionery companies
packaged foods and meals reflect recom-
to agree to continue and strengthen voluntary
mended portion sizes. The relevant federal
restrictions on the marketing and advertising
agencies should also work with the restaurant
of unhealthful foods to youth. The U.S. De-
industry to provide better and more readily ac-
partment of Education and USDA should ban
cessible information about the nutritional con-
all marketing and advertising of unhealthy
tent of menu items. If these voluntary
foods in schools. The relevant federal agencies
measures do not go far enough, the federal
should work with industry and retail outlets to
government should pursue regulatory action.
The Federal Government and Agriculture
The Administration and Congress should re-
examine its child nutrition programs and en-
duce barriers to the domestic production of
sure that they encourage the consumption of
fruits and vegetables, such as government
healthy foods, including the recommended
subsidies for corn, wheat, soybeans, rice, and
daily amount of fruits, vegetables, and whole
cotton. USDA should support farmers mar-
grains. By setting higher nutritional stan-
kets, farm-to-school, urban gardens, and
dards, and expanding food assistance pack-
other programs that incentivize bringing
ages to include more produce (as was done
fresh, locally grown food into communities;
with the Women Infants and Children (WIC)
especially those that are underserved by
program), USDA can increase the demand
major grocery stores. USDA should also re-
for fresh fruits and vegetables.
48
The following analysis is based on a national research project
issue for government to focus on (“very important”
funded by the TFAH and conducted by Greenberg Quinlan Rosner
means they rated it between eight and 10 on a scale
Research and Public Opinion Strategies. The project included
from zero to 10, where 10 means the issue is extremely
eight focus groups conducted in May 2008 among various audi-
important for government to focus on). This represents
ences in four locations, as well as a national survey of 1,026 regis-
a nine-point increase from 2006, when 54 percent rated
tered voters conducted June 1-8, 2008. The margin of error is
such diseases as a very important issue on this scale.
+/- 3.1 percentage points at the 95 percent confidence level.
L The perceived importance of all other health and safety issues
I Obesity is a significant issue that is becoming increas-
has decreased over the past two years. For instance, 70 per-
ingly important. In fact, obesity is the only health or
cent of people rated bioterrorism attacks a very important
safety issue to have grown in importance since 2006.
issue in 2006, compared to just 52 percent now. Similarly, the
L
percent rating developing vaccines for pandemics as very im-
As the table below demonstrates, 63 percent now say
portant dropped from 66 percent in 2006 to 55 percent now.
that “diseases related to obesity” is a very important
Focus on Obesity Grows While Other Issues Become Lower Priorities
Respondents were asked: “Now, I am going to read you a number of health and safety issues facing our country today. For each, please tell me, on a
scale of zero to 10, how important to you that issue is for government to focus on, with zero meaning it is not at all an important issue for govern-
ment to focus on and 10 meaning it is an extremely important issue for government to focus on. You can use any number between zero and 10.”
2006
2008
Net Change
Decreasing diseases related to obesity like diabetes and heart disease
54
63
+9
Preparing for a biological terrorist attack, like anthrax or small pox
70
52
-18
Developing vaccines to prevent a worldwide flu pandemic, like bird flu
66
55
-11
Stopping the spread of infectious diseases, like HIV/AIDS
70
62
-8
Chemical terrorism, like dangerous chemicals being released into drinking water
74
70
-4
Preventing smoking among kids and protecting people from secondhand smoke
52
49
-3
I Obesity and childhood obesity issues raise big con-
L The focus group discussion on obesity centered largely
cerns about the health of the country. Nearly half the
on children and the increasing lack of exercise and poor
country (49 percent) says that the fact that 23 million kids
nutrition among American kids. As one man in Georgia
in the U.S. are overweight and that childhood obesity
put it, “Obesity is a problem because look at the kids
rates have tripled causes them to feel very concerned
today. Instead of going out and play like we did, in my
about the health of the country (81 percent say it makes
generation, they are in front of the TV or game things or
them at least somewhat concerned). Similarly, the fact
watching more soap operas, MTV and VH1.”
that two-thirds of Americans are obese or overweight,
I The public is most receptive to school-based solutions
which is a factor in more than 20 diseases, makes 43 per-
to the obesity crisis that center on kids. Two specific
cent of the country very concerned, and 78 percent at
proposals to fight the obesity epidemic stand out above
least somewhat concerned.
others. Sixty-nine percent of respondents believe that re-
L In a focus group exercise, when asked to circle the
moving junk food from schools and providing healthier
health concern that is of greatest concern to them,
school lunches is a very useful way to combat obesity, while
nearly half of participants (48 percent) chose obesity,
62 percent feel that expanding physical exercise in schools
diseases related to obesity, lack of physical activity, or
is a very useful idea. Giving people incentives to stay fit is
poor nutrition, significantly outpacing infectious dis-
the next-highest rated proposal, but falls a full 18 percent-
eases, aging, and smoking concerns.
age points behind on this scale, at 44 percent very useful.
49
C. READY OR NOT? PROTECTING THE PUBLIC’S HEALTH
FROM DISEASES, DISASTERS, AND BIOTERRORISM --
RECOMMENDATIONS FOR FIXING THE GAPS IN PUBLIC
HEALTH EMERGENCY PREPAREDNESS
Seven years after September 11, 2001, and
The following recommendations were devel-
the anthrax attacks, and three years after
oped through consultation with a range of ex-
Hurricane Katrina, major problems still re-
perts in public health and infectious disease
main in our readiness to respond to large-
preparedness. Since 2003, Trust for Amer-
scale emergencies and natural disasters.
ica’s Health (TFAH) has issued Ready or Not?
The country is still insufficiently prepared to
Protecting the Public’s Health from Diseases, Disas-
protect people from disease outbreaks, nat-
ters, and Bioterrorism, to assess federal and state
ural disasters, or acts of bioterrorism, leav-
preparedness to respond to health emergen-
ing Americans unnecessarily vulnerable to
cies, and provide recommendations for fixing
these threats.
gaps in our nation’s preparedness.
Defining Public Health Preparedness Roles and Responsibilities
The next Administration must address how
land Security (DHS), Veterans Affairs (VA),
public health emergency preparedness and
and Defense (DOD) - - and for offices within
response can be better organized. Many ex-
HHS, including the Assistant Secretary for
perts have called for more clarity around the
Preparedness and Response (ASPR), the
roles and responsibilities of federal agencies
U.S. Centers for Disease Control and Pre-
involved in public health emergency pre-
vention (CDC), and the Health Resources
paredness, including the Departments of
and Services Administration (HRSA).
Health and Human Services (HHS), Home-
The federal government should:
I Ensure a broad understanding of health se-
are needed during emergencies. For ex-
curity issues within the Executive Office of
ample, the VA can manage large health
the President.
systems and the VA and DOD can effec-
L The next Administration should appoint a
tively and rapidly move people, equip-
Deputy Assistant to the President for
ment, and supplies. The White House
Health Security Affairs who can coordinate
Homeland Security Council should review
domestic and global security issues across
Emergency Support Function-8 to deter-
the National Security Council, Homeland
mine whether any changes in protocol are
Security Council, Domestic Policy Council,
needed, and if any new authorities are
and National Economic Council.
needed to permit larger contributions by
VA and DOD during emergencies.
I Harness the broad health response ex-
L While HHS is considered the lead agency
pertise of the various cabinet agencies.
for public health response, some critical
L HHS is the lead cabinet agency for deter-
health functions operate out of the Office
mining policy and planning for emergen-
of Health Affairs, such as the management
cies. There is broad consensus among
of the surveillance system BioWatch, and
experts that HHS should remain as the
related functions are separately managed
lead agency. However, other cabinet agen-
by other HHS agencies, such as the CDC
cies have different types of expertise that
BioSense surveillance system. The White
50
House Homeland Security Council should
all preparedness grants should be managed
review the health-related functions of DHS
by ASPR rather than CDC, even though
and establish a structure to make sure
CDC has traditionally functioned as an op-
these systems are well-coordinated and
erating division and has expertise in man-
housed in the most appropriate agencies.
aging grants. Roles must be clarified. With
I
support from a new Under Secretary of
Ensure appropriate division of labor
Health (USH), ASPR should focus on con-
within HHS.
sistency in policy among programs, to en-
L Under the current structure, ASPR func-
sure that all HHS agencies follow the policy
tions as both a policy arm and operating di-
guidance of ASPR. CDC should continue to
vision. As a policy office, it recommends and
be the main operating division for pre-
oversees policy for all HHS agencies and in-
paredness grants, to avoid adding more bu-
teracts with other cabinet agencies and the
reaucracy and confusion for state and local
White House on preparedness issues. As an
government grantees. (See Section 2B on
operating division, it manages some pro-
Federal Structure for more on the creation
grams including hospital preparedness
of an Under Secretary of Health.)
grants. Some officials have suggested that
Additional priority public health preparedness recommendations include to:
I Restore full funding for preparedness. At
lic health disaster, regardless of their
a minimum, state and local public health
health insurance status or ability to pay. It
emergency preparedness capabilities
would also ensure people with ongoing se-
should be restored to the Fiscal Year 2005
rious health problems receive the “conti-
level of $919 million, and hospital pre-
nuity of care” they need to protect their
paredness programs to the Fiscal Year 2004
health and safety and put into place a
level of $515 million.
framework to ensure hospitals are reim-
bursed for uncompensated care. The Sec-
I Ensure that emergency preparedness is
retary would declare a public health
part of the health reform debate.
emergency and decide to activate the ben-
L The health care system has a crucial role
efit. With appropriate funding from Con-
to play in emergency response. Currently,
gress, the benefit would last for 90 days or
preparedness is encouraged through a
less, though the Secretary could extend it
separate grants program that has received
for an additional 90 days if needed.
ever-declining levels of funding. Insuffi-
I Strengthen surge capacity in hospitals.
cient funds have been provided to build
Surge capacity remains the largest threat
the capacity of hospitals, in particular, to
to the nation’s ability to respond to a
prepare, and no funding streams have
major catastrophe. Recommendations for
been established to ensure reimburse-
strengthening surge capacity include 1) re-
ment for services during a response. Any
gional coordination of healthcare facili-
health care reform proposal should en-
ties, including alternative care sites with
sure that reimbursement rates include re-
public health and emergency manage-
sources for health care providers to create
ment; 2) establishing and supporting al-
and maintain their emergency response
ternative care sites; 3) enhancing
capacity, including capital expenditures.
communication systems; 4) designating a
L A stand-by temporary emergency health
disaster coordinator in each hospital; and
benefit for individuals who are uninsured
5) building a strong surge workforce by re-
or otherwise qualified should be created
cruiting, in advance, in order to ensure li-
to guarantee coverage of emergency treat-
censing and accreditation issues are
ment for victims affected by a major pub-
resolved before an emergency occurs.
51
I Establish clear preparedness standards for
I Modernize technology and equipment.
all states. Preparedness varies from state to
Surveillance systems must be upgraded so
state and community to community. HHS
that they meet national standards and are
has yet to establish clear benchmarks and ob-
interoperable between jurisdictions and
jective standards for preparedness in states.
agencies to ensure rapid information shar-
The objectives should focus on outcome re-
ing. Surveillance systems should be able
sults from real-life drills and exercises. Cur-
to detect an infectious disease outbreak,
rent benchmarks are often process-oriented
and plans should ensure adequate labora-
and are not clear predictors of how well a
tory surveillance of infectious diseases.
state will respond to an emergency.
I Ensure the Strategic National Stockpile has
I Ensure liability protection for volunteers.
treatments for chronic and infectious
Volunteers and private entities have ex-
threats. The stockpile should include med-
pressed reluctance to participate in re-
ications to guarantee that needed treat-
sponse and recovery efforts for fear that
ments are available for chronic conditions,
their actions may make them liable. The fed-
like diabetes, as well as antiviral drugs to
eral government should issue a clear ruling
treat possible emerging infectious diseases.
on what liability protections are offered to
I Modernize risk communications. Hospi-
volunteers under the Stafford Act; state Leg-
tals must develop communication systems
islatures should adopt the Uniform Emer-
that allow health care facilities, public
gency Volunteer Health Practitioners Act;
health departments, and emergency re-
and they should also consider extending the
sponders to talk to each other and collec-
Good Samaritan liability protections to
tively manage a response.
those non-health care volunteers who pro-
vide emergency assistance.
The following analysis is based on a national research project
types of events. Focus group research indicates that while
funded by the TFAH and conducted by Greenberg Quinlan Rosner
there is praise for the response to recent wildfires, concerns
Research and Public Opinion Strategies. The project included
about the response to Hurricane Katrina clearly still remain.
eight focus groups conducted in May 2008 among various audi-
I America’s lack of preparedness for dealing with natu-
ences in four locations, as well as a national survey of 1,026 regis-
ral disasters causes concern. Despite the sense that the
tered voters conducted June 1-8, 2008. The margin of error is
government has responded more effectively to natural dis-
+/- 3.1 percentage points at the 95 percent confidence level.
asters that have occurred since Hurricane Katrina, the fact
I Natural disasters are nearly universally seen as in-
that many U.S. cities and communities still do not have the
evitable. A full 97 percent believes that a major natural disas-
supplies and plans necessary to deal with these emergencies
ter such as a hurricane, tornado, or earthquake is likely to occur
causes people a great deal of concern. Eighty-two percent
in the United States within the next five to 10 years. Eighty-one
say that this fact makes them concerned about the safety of
percent feel that such an event is very likely to happen.
the country, with 53 percent responding that it makes them
I
very concerned.
There is a level of uncertainty about how prepared
the government is to handle a major natural disaster.
I Disaster preparedness is seen as an important role
While people do not necessarily view the government as
for government. Sixty-one percent say that “preparing
completely unprepared to handle a major natural disaster,
for major natural disasters” is a very important issue for
neither do they express a very high level of confidence in the
government to focus on (“very important” means they
government’s ability to respond effectively. Though nearly
rated it between eight and 10 on a scale from zero to 10,
two-thirds say the government and public health system are
where 10 means the issue is extremely important for gov-
prepared to handle a major natural disaster, only 15 percent
ernment to focus on). A full one-third of the country (33
believe these entities are very prepared to handle these
percent) gave this issue a rating of 10.
52
D. FIXING FOOD SAFETY: PROTECTING AMERICA’S
FOOD SUPPLY FROM FARM -TO -FORK --
RECOMMENDATIONS FOR IMPROVING FOOD SAFETY
Approximately 76 million Americans - - one
L An estimated 85 percent of known food-
in four - - are sickened by food-borne disease
borne illness outbreaks are associated with
each year. Of these, an estimated 325,000 are
foods regulated by the U.S. Food and
hospitalized and 5,000 die.65 Medical costs
Drug Administration (FDA), but the
and lost productivity due to food-borne ill-
agency receives less than half of the fed-
nesses are estimated to cost $44 billion an-
eral funding for food safety;
nually.66, 67
Major outbreaks can also
I In the past three years, the main food
contribute to significant economic losses in
safety function at FDA has lost 20 percent
the agriculture and food retail industries.
of its science staff and 600 inspectors;
Experts estimate that most food-borne ill-
I Gaps in current inspection practices mean
nesses could be prevented if the right meas-
acts of agro-terrorism, such as contamina-
ures were taken to improve the U.S. food
tion of wheat gluten or botulism, could go
safety system.
undetected until they are widespread;
Trust for America’s Health (TFAH) consulted
I While 15 federal agencies are involved in
a series of experts to outline problems and
food safety, the efforts are fragmented and
recommendations for fixing the food safety
no one agency has ultimate authority or re-
system in a 2008 report, Fixing Food Safety: Pro-
sponsibility for food safety;
tecting America’s Food from Farm-to-Fork. Major
problems outlined in the report include:
L For instance, the FDA regulates frozen
pizza, but if the pizza is topped with two
I The U.S. food safety system has not been
percent or more of cooked meat or poul-
fundamentally modernized in more than
try, then the Food Safety and Inspection
100 years;
Service (FSIS) at the U.S. Department of
I The bulk of federal food safety funds are
Agriculture (USDA) becomes the regu-
spent on outdated practices of inspecting
latory agency;
every poultry, beef, and pork carcass, even
I Only one percent of imported foods are
though changing threats and modern agri-
inspected. Approximately 60 percent of
culture practices and technology make this an
fresh fruits and vegetables and 75 percent
unproductive use of government resources;
of seafood consumed in the U.S. is im-
I Inadequate resources are spent on fighting
ported; and
modern bacteria threats, such as trying to re-
I States and localities are not required to meet
duce Salmonella or dangerous strains of E. coli;
uniform national standards for food safety.
53
To help fix the food safety system, the federal government should:
I Promote farm-to-fork disease prevention
safety standards, require that food importers
practices. Food safety priorities must shift
demonstrate that these standards are being
from a system focused on outdated, lim-
met, and permit U.S. regulators to inspect
ited end-product and processing plant in-
foreign establishments as well as food at the
spections to a system where the emphasis is
port of entry. Food safety agencies should
placed on preventing outbreaks and ill-
also be given the authority and funding to
nesses throughout the entire food pro-
participate in international negotiations
duction process and supply chain.
and discussions, such as the Codex Alimen-
tarius Commission and the World Trade Or-
L Preventive strategies, such as the Hazard
ganization. Trade agencies regularly take
Analysis and Critical Point Process
the lead in these discussions, but often lack
(HACCP), should be at the center of food
the food safety mission, expertise, and cred-
safety practices. Outdated practices, like
ibility to effectively represent U.S. interests.
those called for in the current FSIS in-
spection mandate, should be repealed.
I Strengthen FDA with increased funding and
resources. Funding for FDA’s food pro-
L Uniform performance standards and best
gram must grow substantially and statutory
practices should be defined and adopted,
mandates should be updated to strengthen
and should be enforceable, including es-
the agency’s abilities to carry out preventive
tablishment registration, records access,
efforts and oversee food imports.
detention and recall authority, and civil
penalty authority.
I Create uniform standards and practices
across federal, state, and local levels.
L Food safety education programs should be
While the states play a critical food safety
mandatory for commercial food handlers
role, particularly at the retail level, the fed-
and consumers.
eral-state-local relationship is not well de-
I Make the food safety system flexible
fined or financed. States and localities
enough to keep pace with modern threats.
should be encouraged and incentivized to
Threats to the food supply change as in-
adopt and comply with the voluntary uni-
dustry practices and farming and process-
form standards and practices of the FDA’s
ing technologies change. Government
Food Code and the National Retail Food
strategies for protecting and inspecting
Regulatory Program.
the food supply must be able to adapt
I Create a single food safety agency. While
quickly to these changes.
immediate action should be taken to ad-
L Ongoing research is needed to identify
dress concerns at FDA, in order to strate-
emerging threats and up-to-date ways to
gically address food safety concerns, make
contain them.
good use of federal resources, and have
stronger national and international lead-
L Government food safety officials and food
ership, the goal over time should be to
companies must be able to keep track of
consolidate and align all federal food
information about disease outbreaks in
safety functions to increase effectiveness,
humans, plants, and animals and results of
responsibility, and accountability. This
food inspections so they can quickly detect
agency could then address the food supply
and contain problems.
as a whole and set priorities accordingly. It
I Monitor foreign imports and international
could oversee regulation and inspection,
practices. Food safety agencies must have
but must also have research and surveil-
clear statutory authority and receive the re-
lance functions as part of its mandate. It
sources necessary to educate overseas regu-
should also be required to report on ac-
lators and food producers about U.S. food
complishments, progress, and problems.
54
L The realigned agency should include: the
a way that not only monitors outbreaks and
USDA’s Food Safety and Inspection Service
helps investigate preventive strategies but
(FSIS), FDA’s Center for Food Safety and
also provides accountability for how well
Applied Nutrition (CFSAN), the Center for
U.S. food safety systems are working.
Veterinary Medicine, the food portion of
While many recommendations for address-
FDA’s field resource, and the food safety as-
ing food safety are focused on government
pects of the U.S. Environmental Protection
actions, the report finds that fixing the food
Agency’s pesticide program.
safety system will require a collaborative ef-
L The placement of the U.S. Centers for Dis-
fort by food producers, processors, distribu-
ease Control and Prevention (CDC) food-
tors, retailers, and consumers, combined
borne disease surveillance program should
with strong leadership from the federal,
be reviewed. It must be able to function in
state, and local government.
The following analysis is based on a national re-
important” means they rated it between
search project funded by TFAH and conducted
eight and 10 on a scale from zero to 10,
by Greenberg Quinlan Rosner Research and
where 10 means the issue is extremely im-
Public Opinion Strategies. The project included
portant for government to focus on). More
eight focus groups conducted in May 2008
than two people out of five (43 percent)
among various audiences in four locations, as
gave this issue a rating of 10.
well as a national survey of 1,026 registered
I Current sense of the safety of our food
voters conducted June 1-8, 2008. The margin
supply is shattered by the lack of regu-
of error is +/- 3.1 percentage points at the 95
lation and inspection of food products
percent confidence level.
coming into the country. Seventy-one
I A major outbreak of food-borne dis-
percent of people believe that the U.S.
ease is seen as highly likely to occur.
government is prepared to handle an out-
Fed by a recent string of outbreaks, in-
break of food-borne disease such as sal-
cluding E. coli in spinach in 2006 and sal-
monella or E. coli. But, when presented
monella in peppers just this year, 78
with the fact that approximately 60 per-
percent of the public believes that an out-
cent of fresh fruits and vegetables and 75
break of food-borne disease is likely to
percent of seafood consumed in the U.S.
occur in the U.S. in the next five to 10
are imported, yet only one percent of im-
years, including 42 percent who believe it
ported foods are inspected, this confi-
is very likely to happen.
dence in government regulation is called
I
immediately into question. Nearly every-
The public views the protection of the
one (88 percent) says that this fact makes
nation’s food supply as a primary gov-
them concerned about the health of the
ernment responsibility. Sixty-five percent
country, with 69 percent responding that it
respond that “protecting food from diseases
makes them very concerned, more than
like salmonella and E. coli” is a very impor-
any other issue tested in this research.
tant issue for government to focus on (“very
55
E. STAMPING OUT SMOKING -- RECOMMENDATIONS
FOR POLICIES TO HELP PREVENT SMOKING AND OTHER
TOBACCO USE
Tobacco use is the leading preventable cause
Nearly 21 percent of U.S. adults still smoke, as
of death in the U.S. Every year, smoking and
do 23 percent of U.S. high school students.71
secondhand smoke kill about 440,000 peo-
While significant reductions were achieved in
ple in the U.S. by causing lung cancer, em-
the late 1990’s and early 2000’s, progress has
physema, heart disease, and other illnesses.68
stalled. The federal government, in partner-
Exposure to second-hand smoke is responsi-
ship with state and local governments, can help
ble for approximately 38,000 of these deaths
reverse this trend. The death toll and devas-
each year.69 Worldwide, tobacco use causes
tating health consequences of tobacco use
nearly five million deaths per year.70
leads to billions of dollars in health care bills.
Health Consequences:
I Smoking harms nearly every organ of the
cervix, kidney, lung, pancreas, and stom-
body; causing many diseases and reducing
ach, and causes acute myeloid leukemia.74
the health of smokers in general.72
I Smoking causes coronary heart disease, the
I Cancer is the second leading cause of death
leading cause of death in the U. S. Smok-
in the U.S.; more than 80 percent of lung
ing triples the risk of dying from heart dis-
cancer deaths and about 20 percent of all
ease among middle-aged men and women.75
cancer deaths are caused by tobacco.73
I Cigarette smoking causes 80 to 90 percent
I Smoking causes cancers of the bladder,
of deaths from chronic obstructive lung
oral cavity, pharynx, larynx, esophagus,
disease.76
High Costs:
I Tobacco use costs the U.S. almost $100 bil-
I People exposed to secondhand smoke run
lion annually in health care bills, imposing a
up an average $10 billion annually in
hidden tax on every individual, family, and
health care costs.78
business. Productivity losses from premature
death total another $97 billion.77
Alarming Trends:
I Every day in America, 4,000 kids try their
followed a 40 percent decline in high
first cigarette. Another 1,000 kids become
school smoking between 1997, when rates
daily smokers and one-third of them will
peaked at 36.4 percent, and 2003.80
die prematurely as a result.79
I Tobacco company marketing expenditures
I Progress in reducing smoking has stalled
have skyrocketed since the 1998 state tobacco
among both youth and adults. In 2006,
settlement. From 1998 to 2005, tobacco mar-
20.8 percent of adults smoked cigarettes,
keting expenditures nearly doubled from
about the same as the 20.9 percent in 2004
$6.9 billion to $13.4 billion, according to the
and 2005. Among high school students,
Federal Trade Commission’s most recent re-
smoking increased from 21.9 percent in
port on tobacco marketing.81
2003 to 23 percent in 2005. This increase
56
I Most states still fail to fund tobacco pre-
tobacco companies on tobacco preven-
vention programs at levels recom-
tion and cessation programs. Investing
mended by the CDC. In FY 2008, states
only 15 percent of these funds would
will spend less than three percent of the
allow ever y state tobacco control pro-
$24.9 billion available to them from to-
gram to be funded at the level recom-
bacco excise taxes and the 1998 Master
mended by the U.S. Centers for Disease
Settlement Agreement (MSA) with the
Control and Prevention (CDC).82
The President and Congress should:
I Regulate tobacco products. Congress
I Fund tobacco prevention initiatives. Con-
should enact long-standing legislation to
gress and the President should increase the
grant the U.S. Food and Drug Administra-
amount the CDC receives in federal gov-
tion (FDA) regulatory authority over to-
ernment funding for tobacco prevention.
bacco products. FDA should have the
I Work with other nations to reduce global
authority to crack down on tobacco mar-
tobacco use and exposure. The U.S.
keting and sales to children, stop tobacco
should help encourage other nations
companies from misleading consumers,
around the world to ratify and implement
and require changes in tobacco products
the new international tobacco control
to make them less harmful and less addic-
treaty, the Framework Convention on To-
tive. Currently, FDA regulates food, drugs,
bacco Control, in order to reduce tobacco
cosmetics, and even dog food but does not
use and save lives.
regulate the products that kill more than
400,000 Americans every year.
State and Local Governments Should:
I Expand proven tobacco control measures.
all workplaces and public places smoke-
State and local leaders should implement
free, full funding of tobacco prevention
proven measures to reduce tobacco use
and cessation programs, and access to
and protect everyone from the harms of
proven smoking cessation methods, such
secondhand smoke. These include to-
as counseling and FDA-approved medica-
bacco taxes, comprehensive laws to make
tions, for all tobacco users.
57
F. SHORTCHANGING AMERICA’S HEALTH --
UNDERSTANDING SOCIAL DETERMINANTS AND
RECOMMENDATIONS FOR IMPROVING THE HEALTH OF
ALL AMERICANS, NO MATTER WHERE THEY LIVE
Every American should have the opportunity
I College graduates can expect to live at
to be as healthy as he or she can be. But now,
least five years longer than individuals who
health varies dramatically from state to state
have not finished high school;
and community to community.
I Poor adults are nearly five times as likely
Access to good medical care is obviously one
to be in poor or fair health than individu-
important factor that impacts how healthy a
als with the highest incomes;
person is, but a number of other factors play
I Children in poor families are about seven
a role in health beyond medical care.
times as likely to be in poor or fair health
In fact, many researchers have found that
as children in the highest-income families;
where you live, your income level, your socio-
I Nearly one in three adults has a chronic ill-
economic group, and behavior often impact
ness that limits their activity compared
your health more than either genetics or ac-
with fewer than one in 10 adults with the
cess to medical care.83, 84, 85
highest incomes; and
Researchers often call factors that are be-
I Babies born to mothers who did not finish
yond an individual’s control “social determi-
high school are nearly twice as likely to die
nants” of health. It is not just about money,
before their first birthdays as babies born
but it is often about the impact money has on
to college graduates.88
the areas where you live and the opportuni-
ties you have. Environmental factors, rang-
Since 2005, Trust for America’s Health
ing from whether a community has safe and
(TFAH) has reviewed key health statistics
accessible parks and recreation spaces to po-
and funding levels for public health on a
tential hazards like lead paint and toxic sub-
state-by-state level in its report, Shortchanging
stances, have a major impact on how healthy
America’s Health: A State-By-State Look at How
people are.86
Federal Public Health Dollars Are Spent. TFAH
found that rates of disease and other health
A recent report from the Robert Wood John-
indicators vary widely from state-to-state and
son Foundation Commission to Build a
community-to-community.
Healthier America concluded that, “it may
sound counterintuitive, but the best way to
Improving the health of all Americans, regard-
reduce America’s medical bills and help
less of race, ethnicity, income, or where they
families ... fight for good health may be to
live should be a top priority for the federal gov-
invest in schools, sidewalks, produce mar-
ernment. Because such a wide variety of fac-
kets, preschool programs, parks, housing,
tors influence health, policies in every agency
and public transit.”87 The Commission re-
of the federal government can have an impact
port found that:
on health, from transportation and housing to
environmental protection and education.
58
The federal government should:
I Provide increased leadership and under-
Key policy areas include: early childhood
standing for how policies and programs
development; economic development ini-
throughout the government impact the
tiatives in low-income communities; pro-
health of Americans. Section 2B of the
moting good nutrition and physical
Blueprint for a Healthier America provides a se-
activities in schools, childcare, and after-
ries of recommendations for restructuring
school programs; preventing smoking and
federal health agencies to increase leader-
other tobacco use; and strengthening sup-
ship, maximize efficiency and coordination,
port for low-income individuals to attend
for building better interdepartmental col-
community college, vocational programs,
laboration at the federal level, and assessing
and college.89 Staff at the U.S. Department
policies and programs across government
of Health and Human Services (HHS)
agencies to consider how they might impact
should have training about prevention and
the health of Americans. The federal gov-
social determinants of health.
ernment should provide leadership on the
I Engage representatives from all types of
issue to state and local governments. At all
communities in developing policies to im-
levels of government, strategies and goals
prove health. The views, concerns, and
for improving determinants of health need
needs of community stakeholders, such as
to be articulated succinctly and clearly, and
volunteer organizations, religious organi-
programs that affect social determinants --
zations, and schools and universities must
from education to anti-poverty programs --
be taken into account when developing
must recognize the role they play in health
policies if they are to be successful.
improvement.
I Create systems of accountability for im-
I Fully fund and promote policies that stress
proving the health of communities. The
disease prevention. The government
government should ensure that policies
should ensure policies and programs will
are linked to accountability measures to es-
help give Americans the environment and
tablish clear responsibilities and mecha-
tools they need to live healthier lives, such
nisms to determine where improvements
as supporting safe and accessible recre-
need to be made, including measuring
ation spaces, affordable nutritious foods,
progress on social determinants as poten-
ways to prevent and avoid smoking and
tial markers for improving health. For
other tobacco use, clean air, water, and
more recommendations, see Section 2C of
land, and safe communities where acci-
the Blueprint for a Healthier America.
dents and injuries can be better avoided.
59
G. HEALTHY WOMEN, HEALTHY BABIES --
RECOMMENDATIONS FOR IMPROVING INFANT HEALTH
Improvements in maternal and infant health
Traditionally, health services to improve birth
in the U.S. have stalled since 2000.90 After 40
outcomes have been focused on prenatal care
years of progress, infant mortality rates have
during pregnancy and the time of birth. But,
not improved -- in fact, infant mortality rates
increasing evidence shows that how healthy a
in the U.S. rank 27th behind many other in-
woman is even before she becomes pregnant
dustrialized nations.91
has a great impact on the health of the baby
and whether there is an increased risk for in-
Doctors fear that the health of America’s
fant death or birth defects.
babies may start to move in the wrong
direction because the health of childbearing
Approximately 62 million American women
aged women is starting to get worse, and this
are of childbearing age.92 By the age of 25,
is happening more rapidly among low-
about half of all women in the U.S. give birth.
income women.
By age 44, 85 percent of women give birth.93
The federal government should:
I Make it a priority to find ways to improve
Health Block Grants, and Title X Family
the health of infants in the U.S. federal
Planning programs, and allow these pro-
agencies should provide seed support to
grams to pool resources to collectively ad-
state and local governments to develop
dress maternal and infant health.
models to bring together existing pro-
Some states, including Illinois, are already
grams to improve women’s health and
trying this approach. The federal govern-
birth outcomes. For instance, every effort
ment must provide waivers to allow states to
should be made to coordinate relevant
use their funds more efficiently.
Medicaid, Title V Maternal and Child
ILLINOIS HEALTHY WOMEN: AN EXAMPLE OF A
COORDINATED APPROACH
The Illinois Healthy Women initiative is a five-year demonstration project designed to improve
the health of women and their future children, placing a focus on providing care to women
throughout their childbearing years. The state has focused on expanding access to women’s
health care services, particularly by expanding Medicaid services to include coverage for adult
preventive care and risk assessments, recommending content for annual preventive visits, and
enhancing outreach to locate high-risk pregnant women.94
The strategy includes: identifying women at high risk and with chronic conditions; establishing
medical homes for women; and providing care management. Illinois received a waiver under
the State Children’s Health Insurance Program (SCHIP) to operate a Family Care program,
which provides health insurance to parents with incomes equal to or less than 90 percent of
the Federal Poverty Level, and Illinois has used state funds to expand coverage to people
within 133 percent of the Federal Poverty Level.
60
The federal government should also:
I Ensure that federal programs maximize
I Provide adequate funding for other pro-
the health of women of childbearing age
grams that provide primary care to women
by supporting preconception care and ex-
of childbearing age, including:
panding current or creating new programs
L The Healthy Start Infant Mortality
that ensure equitable access to preconcep-
Reduction Program;
tion care to all women, regardless of in-
L Community Health Centers;
come, race, or ethnicity.
L Title X Family Planning; and
I Ensure all existing Medicaid options for
L The Title V Maternal and Child Health
prenatal care are fully implemented in
Block Grant.
every state, including:
L Appropriate reimbursement levels;
I Increase funding for research on precon-
L
ception health and health care, including
Presumptive eligibility;
providing more resources for:
L Improved treatment for psycho-social
L The National Center on Birth Defects
risks; and
and Developmental Disabilities at the
L Postpartum coverage.
U.S. Centers for Disease Control and
I Enhance Medicaid to include coverage for:
Prevention (CDC) and
L Family planning;
L The Eunice Kennedy Shriver National
L Low-income adult women; and
Institute of Child Health and Human
L
Development of the National Institutes
24 months following a Medicaid-
of Health.
financed birth.
61
Section 4
OVERVIEW OF FEDERAL
PUBLIC HEALTH AGENCIES
AND BUDGETS
SECTION
4
SECTION
4
Overview of Federal
Public Health Agencies
4
S E C T I O N
and Budgets
This section provides an overview of the federal government’s public
heath programs housed within the U.S. Department of Health and
Human Services (HHS). It includes missions; organizational charts; brief de-
scriptions of the major programs or activities managed by agency or office;
and a brief funding history.
Information in the organizational charts reflects the current structure of each
office, which may differ from the recommendations contained in other por-
tions of the Blueprint for a Healthier America.
FUNDING SHORTFALLS
The funding histories reflect the agency’s ap-
count the demand for increased services.
propriations from fiscal year (FY) 2005 through
For example, funding for the Ryan White
FY 2008, and includes the partial-year funding
HIV/AIDS program has marginally in-
provided in a FY 2009 Continuing Resolution,
creased, but the funding has not kept up
which runs through March 6, 2009, and then
with inflation or the substantial increase in
show what the funding level would be after ad-
people needing services. Therefore, the
justing for inflation. Inflation adjustments
program had seen a real cut of $158 million
were calculated using the Bureau of Labor Sta-
since FY 2005.
tistics Consumer Price Index (CPI) Inflation
Similarly, funding for the Maternal and Child
Calculator.95 With respect to the National In-
Health Block Grant has declined over the last
stitutes of Health (NIH), inflation adjustments
four years, and when factoring in inflation, it
were calculated using the Bureau of Labor Sta-
experienced a real cut of $146 million, not
tistics/NIH Biomedical Research and Devel-
withstanding the large number of women
opment Price Index.96
and children in need of additional services.
The funding charts are intended to demon-
Maternal and child health experts support a
strate cuts or increases to public health
funding level of $850 million in FY 2009 in
service programs over four full fiscal years, and
order to provide adequate service delivery.
the period from October 1, 2008 to March 6,
In other cases, investments in national prior-
2009 (which is when the current Continuing
ities, especially those related to emergency
Resolution is set to expire) in real dollars.
preparedness, may provide an inaccurate
At the overall program level, some agencies
view of the overall agency budget. The U.S.
may have experienced a marginal funding in-
Centers for Disease Control and Prevention
crease or a seemingly insignificant decrease
(CDC) is one example. Investments in
in funding. In some cases this is deceptive be-
bioterrorism and pandemic influenza
cause the dollar figures do not take into ac-
preparedness have significantly increased the
63
agency’s overall funding level since Septem-
and run a statewide coordinated school
ber 11, 2001, (although the funds have sig-
health program that reduces chronic dis-
nificantly fluctuated year-to-year), yet many
ease risk factors, including tobacco use,
of CDC’s core programs have been repeat-
poor nutrition, and inadequate physical
edly cut. For example:
activity. At current funding levels, the pro-
I
gram is only able to fund 22 states and one
In 2005, the Preventive Health and Health
tribal government. An additional $20 mil-
Services Block Grant (PHHSBG) was
lion would be necessary to support all
funded at $119 million. The PHHSBG is
states that applied for the funding.
distributed to states, territories, and tribal
governments to support key public health
I HIV/AIDS programs at CDC focus on pre-
programs in communities. When that fig-
vention, screening, and early detection of
ure is adjusted for inflation, the block
the virus. In FY 2008, these programs were
grant has seen a cut of $36 million over
funded at $1,002 million, a cut of $75 mil-
the last four years.
lion since FY 2004 (with inflation). Re-
I
cently the agency submitted a professional
In FY 2007, the Division of Nutrition, Phys-
judgment budget to Congress that recom-
ical Activity, and Obesity (DNPAO) gave
mended an additional $877 million in FY
grants to 28 states for state health depart-
2009 and an additional $4.8 billion over
ments to design, implement, evaluate, and
five years.
disseminate effective mitigation interven-
tions. In FY 2008, DNPAO cut the number
Even CDC funding for all-hazards prepared-
of grantees from 28 to 23 states due to in-
ness has experienced cuts. In FY 2005, fund-
sufficient funding. It would cost $90 mil-
ing for states and localities to improve
lion to fund all the states at the level for
bioterrorism preparedness was $919 million;
which they applied.
in FY 2008, it was $767 million. When infla-
I
tion is factored in, this represents a cut of
The Adolescent and School Health pro-
$264 million.
gram provides grants to states to establish
PANDEMIC FLU
Preparedness for an outbreak of pandemic in-
ing to HHS. In FY 2007 and FY 2008, while
fluenza has been a priority of the Bush Admin-
Congress provided funding for recurring pre-
istration. Funding for pandemic flu programs
paredness activities, it failed to provide the
has been spread across federal departments
$870 million requested in FY 2008 for activi-
and agencies, although HHS has received the
ties such as expanding vaccine production ca-
major share of pandemic appropriations.
pacity, purchasing antivirals, and accelerating
research and development of rapid diagnostic
In November 2005, President Bush requested
tests. All funding for state and local pan-
$7.1 billion over three years for emergency
demic preparedness ($600 million appropri-
funding for pandemic influenza prepared-
ated in FY 2006) has been allocated, with no
ness. However portions of this request have
indication from the Administration or Con-
not been fully funded. In FY 2006, Congress
gress that additional funds are forthcoming.
appropriated $5.6 billion in emergency fund-
64
THE U.S. DEPARTMENT OF HEALTH
AND HUMAN SERVICES (HHS)
HHS is the U.S. government’s principal agency for protecting the health of all
Americans and providing essential human services. The department is responsible
for overseeing the U.S. Public Health Services Agencies.
HHS ORGANIZATIONAL CHART97
Director, Intergovernmental
Secretary
Chief of Staff
Affairs and Secretary’s
Regional Representatives
Deputy Secretary
Executive Secretary
Assistant
Administrator,
Assistant
Secretary,
Agency for
General Counsel
Secretary for
Administration for
Toxic
Health
Children and
Substances and
Families
Disease Registry
Chief
Administrative
Assistant
Assistant
Commissioner,
Law Judge, Office
Secretary for
Secretary,
Food and Drug
of Medicare
Administration
Administration
Administration
Hearings and
and Management
on Aging
Appeals
Director,
Program
Administrator,
Administrator,
Director, Office
Support
Center for
Health Resources
of Civil Rights
Center
Medicare &
and Services
Medicaid Services
Administration
Assistant
Secretary for
Director, Center
Resources and
for Faith-Based
Director, Agency
Director, Indian
Technology
and Community
for Healthcare
Health Service
Initiatives
Research and
Quality
Assistant
Secretary for
Planning and
Inspector
Evaluation
Director,
Director,
General
Centers for
National
Disease Control
Institutes of
Assistant
and Prevention
Health
Secretary for
Chair,
Preparedness and
Departmental
Response
Review Board
Administrator,
Substance Abuse
Assistant
and Mental Health
Director, Office
Secretary for
Services
of Global Health
Public Affairs
Administration
Affairs
National Coordinator,
Office of the National
Coordinator for Health
Information Technology
65
AGENCY FOR HEALTHCARE RESEARCH
AND QUALITY (AHRQ)
MISSION
To improve the quality, safety, efficiency,
and effectiveness of health care for all Americans.
AHRQ ORGANIZATIONAL CHART98
Office of the Director
Deputy Director
Office of Extramural
Office of
Office of Performance
Center for Delivery,
Research, Education
Communications
Accountability,
Organization and
and Priority
and Knowledge
Resources and
Markets
Publications
Transfer
Technology
Center for Financing,
Center for Outcomes
Center for Primary
Center for Quality
Access and Cost
and Evidence
Care, Prevention and
Improvement and
Tends
Clinical Partnerships
Patient Safety
CENTERS AND MAJOR PROGRAMS
I Center for Outcomes and Evidence. This I Center for Financing, Access, and Cost
center supports research and assess-
Trends. This center examines the cost
ment of health care practices and
of health care and access to services.
technologies.
L Medical Expenditures Panel Survey
I Center for Primary Care, Prevention, and
(MEPS): About $55 million of AHRQ’s
Clinical Partnerships. This center ex-
budget is spent on the Medical Ex-
pands the knowledge base for clinical
penditures Panel Survey. MEPS col-
providers and patients to translate
lects national estimates of health care
knowledge of systems improvement
use and expenditures and also devel-
into primary care practices.
ops data on cost and savings estimates
I
of proposed policy changes.
Center for Delivery, Organization, and Mar-
kets. This center provides expertise for
I Center for Quality Improvement and Patient
advances in health care delivery.
Safety. The purpose of this center is to
improve quality and safety of health
care system through research and evi-
dence implementation.
66
AHRQ FUNDING HISTORY
AHRQ
FY 2005
FY 2006
FY 2007
FY 2008
FY 2009
FY 05
FY 2009
Major Program
Actual
Actual
Actual
Enacted
CR
Inflated
CR+/- Inflated
to $ 08
to $08
Total Program Level
$319
$319
$319
$335
$335
$358
($23)
Health Cost, Quality, and Outcomes Research
$261
$261
$261
$277
$277
$293
($16)
Patient Safety Research
$84
$84
$84
$79
$79
$94
($15)
Health Information Technology
$50 $50 $50 $45 $45 $56 ($11)
General Patient Safety Research
$34 $34 $34 $34 $34 $38
($4)
Effective Healthcare Program
$15
$15
$15
$30
$30
$17
$13
Value-Driven Health Care
--
--
--
$4
$4
Other Quality & Cost Effectiveness Research
$162
$162
$162
$164
$164
$182
($18)
Medical Expenditures Panel Surveys (MEPS)
$55
$55
$55
$55
$55
$62
($7)
Program Support
$3
$3
$3
$3
$3
$3
$0
Source: HHS Budget in Brief -- FY 2009, 2008, 2007
67
U.S. CENTERS FOR DISEASE CONTROL
AND PREVENTION (CDC)
MISSION
To promote health and quality of life by preventing
and controlling disease, injury, and disability.
CDC ORGANIZATIONAL CHART99
Office of the
CDC
Office of
Chief Science
Strategy and
Officer
Innovation
Office of Chief
Office of
of Public Health
Workforce and
Practice
Director
Career
Development
Office of Chief
Operating
Office of Chief
Officer
of Staff
CDC
Office of Dispute Resolutions
Washington
& Equal Employment
Office
Opportunity
Coordinating
Coordinating
Coordinating
Coordinating
Coordinating
Coordinating
National
Center for
Office for
Center for
Center for
Center for
Center for
Institute for
Global Health
Terrorism
Environmental
Health
Health
Infectious
Occupational
Preparedness
Health and
Information
Promotion
Diseases
Safety and
& Emergency
Injury
Services
Health
Response
Prevention
National Center on
National Center for
National Center for
National Center
Birth Defects and
Immunization and
Environmental Health/Agency
for Health
Developmental
Respiratory Diseases
for Toxic Substances & Disease
Marketing
Disabilities
Registry
National Center for
National Center
National Center for
National Center for Injury
Zoonotic, Vector-
for Health
Chronic Disease
Prevention and Control
Borne and Enteric
Statistics
Prevention and Health
Diseases
Promotion
National Center
National Center for HIV/AIDS,
for Public
Viral Hepatitis, STD and TB
Health
Prevention
Informatics
National Center for Preparedness
Detection and Control of
Infectious Disease
68
CENTERS AND MAJOR PROGRAMS
I Coordinating Center for Health Promotion
• Division of Adolescent and School Health
(CoCHP). The CoCHP is made up of the
(DASH). DASH seeks to prevent serious
National Center on Birth Defects and De-
health risk behaviors among children,
velopmental Disabilities (NCBDDD), the
adolescents and young adults. Within
National Center for Chronic Disease Pre-
DASH, the School Health Program
vention and Health Promotion (NCCD-
provides grants to states to establish
PHP), and the Office of Genomics and
and run a statewide coordinated
Disease Prevention.
school health program that reduces
chronic disease risk factors, including
L National Center on Birth Defects and De-
tobacco use, poor nutrition, and inad-
velopmental Disabilities (NCBDDD). The
equate physical activity. Examples of
mission of the NCBDDD is to promote
program activities include completion
the health of babies, children, and
of a walking trail, inclusion of healthy
adults, and enhance the potential for
options at concession stands, and in-
full, productive living.100 The center
clusion of afterschool activities pro-
focuses on prevention, treatment, and
moting physical fitness.
research on birth defects and develop-
mental disabilities.
• PHHS Block Grant (PHHSBG). The
PHHSBG block grant is provided to
L National Center for Chronic Disease Pre-
states, territories, and American In-
vention and Health Promotion (NCCD-
dian tribes for use on prevention and
PHP). The NCCDPHP leads the
health promotion programs for a re-
“nation’s efforts to prevent and control
gion’s particular public health
chronic diseases.”101 Programs under
needs.102 The goals of the grant are
this center include: Cancer Control;
to: create healthy communities; im-
Diabetes; Healthy Youth; Heart Dis-
prove disease surveillance; increase
ease and Stroke; Nutrition, Physical
life expectancy; promote healthy
Activity, and Obesity; the Preventive
aging; and achieve health equity.103
Health and Health Services (PHHS)
Block Grant; and others.
L Office of Genomics and Disease Prevention.
This office “promotes the integration of
• Division of Nutrition, Physical Activity,
genomics into public health research,
and Obesity (DNPAO). This division is
policy, and practice in order to improve
responsible for obesity prevention and
the lives and health of all people.”104
control activities, and in FY 2007, gave
grants to 28 states for state health de-
I Coordinating Center for Infectious Diseases
partments to design, implement, eval-
(CCID). The CCID is composed of the
uate and disseminate effective obesity
National Center for HIV/AIDS, Viral
mitigation interventions. Interven-
Hepatitis, STD, and TB Prevention
tions have included making policy
(NCHHSTP); the National Center for
changes to encourage access to healthy
Immunizations and Respiratory Dis eases
foods, promoting increased physical
(NCIRD); the National Center for Zoo -
activity, and strengthening obesity pre-
notic, Vector-Borne, and Enteric Diseases
vention and control programs in
(NCZED); and the National Center for
preschools, child care centers, work
Preparedness, Detection, and Control of
sites, and other community settings.
Infectious Diseases (NCPDCID).
69
L National Center for HIV/AIDS, Viral Hep-
L National Center for Preparedness, Detec-
atitis, STD, and TB Prevention (NCHH-
tion, and Control of Infectious Diseases
STP).
The NCHHSTP “integrates
(NCPDCID). The NCPDCID works on
epidemiology, laboratory science, and
“improving preparedness and re-
intervention and prevention initia-
sponse capacity for new and complex
tives related to a broad range of STDs
infectious disease outbreaks, and will
to enhance opportunities to develop
manage and coordinate emerging in-
and implement collaborative public
fectious diseases, integrate laboratory
health interventions with shared at-
groups, an facilitate increased quality
risk populations.”105
and capacity in clinical laboratories.”108
• HIV/AIDS. HIV/AIDS programs at
I Coordinating Center for Environmental
CDC focus on prevention, screening,
Health and Injury Prevention (CCEHIP).
and early detection of the virus.
The CCEHIP is composed of the Na-
L
tional Center for Environmental Health
National Center for Immunizations and
(NCEH), the Agency for Toxic Sub-
Respiratory Diseases (NCIRD).
The
stances and Disease Registry (ATSDR),
NCIRD is “an interdisciplinary im-
and the National Center for Injury Pre-
munization program that brings to-
vention and Control (NCIPC).
gether vaccine-preventable disease
science and research with immuniza-
L National Center for Environmental Health
tion program activities.”106
(NCEH). The NCEH “provides na-
tional leadership in preventing and
• Vaccines for Children Program (VFC). The
controlling disease and death result-
VFC program provides no-cost vac-
ing from the interactions between
cines to those under age 18 who fall
people and their environment.”109
into one of the following categories:
Medicaid eligible, uninsured, Ameri-
• Biomonitoring. For more than 30 years,
can Indians or Alaska Natives, and re-
the Environmental Health Laboratory
ceipt of immunization at federally
of the National Center for Environ-
qualified health centers if health in-
mental Health has been performing
surance does not cover vaccines. This
biomonitoring measurements. Bio-
is CDC’s only entitlement program
monitoring is the direct measurement
and is linked to state Medicaid plans.
of people’s exposure to toxic sub-
stances in the environment.
• Influenza. CDC’s seasonal flu pro-
grams also fall under the NCIRD.
• Health Tracking. It can take years for
L
disease symptoms caused by expo-
National Center for Zoonotic, Vector Borne,
sure to environmental hazards to ap-
and Enteric Diseases (NCVZED). The
pear. This disease surveillance or
NCVZED “provides national and in-
tracking program helps states to iden-
ternational scientific and program-
tify the precise environmental causes
matic leadership addressing zoonotic,
of chronic diseases, which are re-
vector-borne, foodborne, waterborne,
sponsible for 70 percent of deaths in
mycotic, and related infections to
the U.S. and three quarters of U.S.
identify, investigate diagnose, treat,
health care spending.
and prevent these diseases.” 107
70
L Agency for Toxic Substances and Disease
vides national leadership in the appli-
Registry (ATSDR). ATSDR “serves the
cation of information technology in
public by using the best science, taking
the pursuit of public health.”114
responsive public health actions, and
I Coordinating Office for Global Health (COGH).
providing trusted health information
The COGH “provides national leadership,
to prevent harmful exposures and dis-
coordination, and support for CDC’s
eases related to toxic substances.”110
global health activities in collaboration
L National Center for Injury Prevention and
with CDC’s global health partners.”115
Control (NCIPC). The NCIPC “pre-
I Coordinating Office for Terrorism Preparedness
vents death and disability from non-
and Emergency Response (COTPER). COT-
occupational injuries, including those
PER “helps the nation prepare for and re-
that are unintentional and those that
spond to urgent public health threats by
result from violence.”111
providing strategic direction, coordina-
I Coordinating Center for Health Information
tion, and support for all of CDC’s terror-
and Service (CCHIS). The CCHIS is made
ism preparedness and emergency
up of the National Center for Health
response activities.”116
Marketing (NCHM), the National Cen-
L Public Health Emergency Preparedness Co-
ter for Health Statistics (NCHS), and the
operative Agreements. Emergency pre-
National Center for Public Health In-
paredness funding for state and local
formatics (NCPHI).
public health departments is distrib-
L National Center for Health Marketing
uted through COTPER. With these
(NCHM). The NCHM “provides na-
funds, state and local health depart-
tional leadership in health marketing
ments have enhanced their disease
science and in its application to im-
surveillance systems and trained their
prove public health.”112
staff in emergency response.
L National Center for Health Statistics
L Division of the Strategic National Stockpile
(NCHS). The NCHS “provides statis-
(SNS). The SNS is a “national reposi-
tical information that guides actions
tory of antibiotics, chemical antidotes,
and policies to improve the health of
ant toxins, life support medications,
the American people.”113
and medical supplies that can be used
to supplement state and local re-
L National Center for Public Health Infor-
sources during a large-scale public
matics (NCPHI).
The NCPHI “pro-
health emengency.”117
71
CDC FUNDING HISTORY
CDC
FY 2005
FY 2006
FY 2007
FY 2008
FY 2009
FY 05
FY 2009
Major Program
Actual
Actual
Actual
Enacted
CR
Inflated
CR+/- Inflated
to $ 08
to $08
Total Program Level (w/ATSDR)
$7,980 $8,602 $9,116 $9,209 $9,209 $8,952
$257
Total Program Level
(w/ATSDR & w/out VFC)*
$6,477
$6,628 $6,381 $6,473 $6,507 $7,266
($759)
Infectious Diseases
$1,679 $1,695 $1,810 $1,905 $1,905 $1,883
$22
Immunization and Respiratory Diseases
$496
$520
$585
$685
$685
$556
$129
HIV/AIDS, Viral Hepatitis, STD and
TB Prevention
$979
$963
$1,003
$1,002
$1,002
$1,098
($96)
Zoonotic, Vector-Borne, and Enteric Diseases
$85
$88
$69
$68
$68
$95
($27)
Preparedness, Detection, Control of Infections
$120
$124
$153
$150
$150
$135
$15
Health Promotion
$1,024 $958 $947 $961 $961 $1,149 ($188)
Chronic Disease Prevention, Health
Promotion, and Genomics
$900
$834
$825
$834
$834
$1,010
($176)
Birth Defects, Developmental Disabilities,
Disability, and Health
$125
$124
$122
$127
$127
$140
($13)
Health Information & Service Total
$229 $219 $270 $277 $277 $257
($20)
Environmental Health & Injury Prevention
$289 $287 $283 $289 $289 $324
($35)
Environmental Health
$151
$149
$147
$155
$155
$169
($14)
Injury Prevention and Control
$138
$138
$136
$135
$135
$155
($20)
Occupational Safety and Health
$251 $263 $265 $382 $382 $282
$100
Global Health
$317 $380 $307 $302 $302 $356
($54)
Public Health Improvement & Leadership
$247 $264 $203 $225 $225 $277
($52)
PHHS Block Grant
$119 $99 $99 $97 $97 $133 ($36)
Buildings & Facilities
$270 $158 $134 $55 $55 $303 ($248)
Business Services Support
$319 $318 $378 $372 $372 $358
$14
Terrorism
$1,623 $1,631 $1,473 $1,479 $1,479 $1,821
($342)
PHS Evaluation Transfers (non-add)
$265 $265 $265 $326 $326 $297
$29
Agency for Toxic Substances and
Disease Registry (ATSDR)
$76 $74 $75 $75 $75 $85 ($10)
Vaccines for Children
$1,503 $1,974 $2,735 $2,736 $2,702 $1,686
$1,016
Energy Employees Occupational Illness
Compensation Program
-
-
$52 $55 $55 -
-
User Fees
$2 $2 $2 $2 $2 $2
$0
* The Vaccines for Children program is mandatory. It is an entitlement program based on population estimates
and paid for through the Medicaid program. The CDC budget data is presented with the VFC funding (first
line) and without VFC (second line) so that the CDC’s discretionary budget can be viewed separately.
Source: Budget Request Summary, CDC Financial Management Office, Fiscal Years 2009, 2008, 2007
72
FOOD AND DRUG ADMINISTRATION (FDA)
MISSION
Protecting the public’s health by assuring the safety and security of the food supply;
the safety, efficacy, and security of human and veterinary drugs; the safety of
biological products and medical devices; the safety and security of cosmetics and
products that emit radiation; and advancing the public health by helping to speed in-
novations that make medicines safer and more effective.
FDA ORGANIZATIONAL CHART118
Office of the
Office of External
Administrative Law
Relations
Judge
Commissioner
Office of the Chief
Office of the
Office of the Chief
Counsel
Principal Deputy
Executive
of Staff
Commissioner and Chief
Secretariat
Scientist
Office of Equal
Employment Opportunity
Office of Legislation
and Diversity Management
Office of Public
Affairs
Center for
Office of
Office of Policy,
Office of
Biologics
Operations and
Planning and
Regulatory Affairs
Evaluation and
Chief Operating
Preparedness
Research
Officer
Office of
Office of
Scientific and
International
Medical
and Special
Office of
Office of
Programs
Programs
Center for Food
Center for Drug
Information
Integrity and
Safety and
Evaluation
Management
Accountability
Applied Nutrition
Research
Office of
Office of
Office of
Critical Path
International
Management
Office of Counter-
Programs
Programs
Terrorism and
Center for
Center for
Emerging
Veterinary
Devices and
Trhreats
Office of
Office of
Medicine
Radiological
Science and
Office of
Executive
Health
Health
Pediatric
Operations
Office of
Coordination
Therapeutic
Policy and
Planning
Office of
National
Office of
Crisis
Center for
Combination
Management
Toxicological
Products
Research
73
CENTERS AND MAJOR PROGRAMS
I Center for Biologics Evaluation and Research (CBER).119 CBER I Center for Food Safety and Applied Nutrition (CFSAN).122 CFSAN
regulates products such as blood and blood products,
is responsible for keeping the nation’s food supply safe and
vaccines, and protein based drugs. CBER also deals with
sanitary and for making sure products are labeled properly.
bioterrorism-related drugs.
CFSAN regulates all food except meat, poultry, and eggs,
I
which are regulated by the Department of Agriculture.
Center for Devices and Radiological Health (CDRH).120 CDRH
ensures that medical devices, from contact lenses to hip
I Center for Veterinary Medicine (CVM).123 CVM ensures the
joints or a robotic arm used for surgeries, are safe. Simi-
safety of “food-producing” animals, as well as the safety and
larly, it sets safety standards for devices that emit radiation,
effectiveness of the drugs produced for these and other an-
such as microwaves, cell phones, and televisions.
imals. It is also the nation’s primary defense against bovine
I
spongiform encephalopathy (BSE), commonly referred to
Center for Drug Evaluation and Research (CDER).121 CDER
as Mad Cow Disease.
“promotes and protects the health of Americans by ensur-
ing that all prescription and over-the-counter drugs are safe
I National Center for Toxicological Research (NCTR).124 NCTR con-
and effective.” All new drugs go through CDER before-
ducts research and technical assistance related to all of the
they are approved, and CDER also monitors direct to con-
areas that FDA covers, such as food safety, bioterrorism, and
sumer drug advertising to ensure accuracy.
antimicrobial resistance.
FDA FUNDING HISTORY
FDA
FY 2005 FY 2006 FY 2007 FY 2008
FY 08
FY 2009
FY 05
FY 2009
Actual
Actual
Actual
Enacted
Supplemental CR
Inflated
CR
+/-
Appropriation
to $08
Inflated
Major Program
(Enacted 06/08)
to $08
Foods
$436 $439 $457 $510
$577 $489 $88
Human Drugs
$496
$518
$565
$680
$708
$556
$152
Biologics
$172 $195 $209 $236
$249 $193 $56
Animal Drugs and Feeds
$98
$99
$104
$109
$115
$110
$5
Medical Devices
$250
$261
$273
$284
$304
$280
$24
National Center for Toxicological Research
$40
$41
$42
$44
$47
$45
$2
Headquarters & Office of the Commissioner**
$115
$117
$122
$133
$133
$129
$4
FDA Consolidation at White Oak
$21
$22
$26
$39
$39
$24
$15
GSA Rental Payments
$129
$134
$146
$159
$159
$145
$14
Other Rent & Rent Related Activities
$36
$36
$50
$61
$61
$40
$21
Export/Color Certification Fund
$7
$8
$8
$10
$10
$8
$2
Subtotal, Salaries & Expenses
$1,801 $1,869
$2,003 $2,264
$2,414
$2,020
$394
Buildings & Facilities
$0
$8
$5
$2
$2
$2
National Center for Natural Products Research
—
—
—
$4
$4
Total Program Level
$1,801 $1,876 $2,008 $2,270
$2,420 $2,089
$331
Less User Fees:
Prescription Drug (PDUFA)
-$284
-$305
-$352
-$459
-$459
Medical Device (MDUFMA)
-$34
-$40
-$44
-$48
-$48
Animal Drug (ADUFA)
$38
-$11
-$12
-$14
-$14
Mammography Quality Standards Act (MQSA)
-$17
-$17
-$18
-$18
-$18
Export/Color Certification Fund
-$7
-$8
-$8
-$10
-$10
Subtotal, User Fees
-$350
-$382
-$434
-$549
-$549
Total Budget Authority***
$1,450 $1,495 $1,574 $1,720
$150*
$1,870 $1,626 $244
*Funds were appropriated in June of FY 2008 but may be spent in FY 2009, in addition to funds made available under
the FY 2009 Continuing Resolution. **In FY 04 and 05, there was no “headquarters & Office of the Commissioner;”
numbers in those years reflect “other activities. ***Total Budget Authority is the Total Program Level minus user fees.
74
Source: HHS Budget in Brief; FY 2009, 2008, 2007; Public Law 110-252; Public Law 110-329
HEALTH RESOURCES AND SERVICES
ADMINISTRATION (HRSA)
MISSION
Improving access to health care services for those who are uninsured and/or who live
in medically underserved areas.
HRSA ORGANIZATIONAL CHART125
HRSA
Office of
Administrator
Office of
Information
International Health
Technology
Affairs
Deputy
Office of
Administrator
Office of Equal
Legislation
Opportunity and
Civil Rights
Office of
Center for
Office of Planning
Communications
Quality
and Evaluation
Office of
Office of Minority Health
Management
and Health Disparities
Office of
Office of
Office of
Office of
Office of
Financial
Federal
Rural Health
Health
Performance
Management
Assistance
Policy
Information
Review
Management
Technology
Bureau of
Maternal
Bureau of
HIV/AIDS
Bureau of
Primary
and Child
Health
Bureau
Clinician
Health Care
Health
Professions
Recruitment
Bureau
and Service
BUREAUS AND MAJOR PROGRAMS126, 127
I Bureau of Primary Health Care. This Bu- I Bureau of Health Professions (BHP). BHP
reau oversees community health cen-
provides leadership in the “develop-
ters, migrant health centers, health care
ment, distribution, and retention” of the
programs for the homeless, and public
health workforce.
housing health service grants.
I Health Professions. In FY 2008, Health
I Community Health Centers (CHCs). In FY
Professions received $623 million in fed-
2008, about one-third of HRSA’s budget
eral training dollars for nurses and other
(about $2 billion) was allocated for com-
heath professions, educational loan re-
munity health centers. CHCs provide pri-
payment and scholarship programs, and
mary health care services to an estimated
recruitment funds.
17 million low-income individuals.
75
I Area Health Education Centers (AHECs).
Inventory, which provides funds to cord
AHECs link university health science
blood banks for transplantation use; the
centers with community health systems
C.W. Bill Young Cell Transplantation Pro-
to provide training sites for students, fac-
gram, which is a bone marrow donor reg-
ulty, and health practitioners.
istry; the Office of Pharmacy Affairs,
which promotes access to clinically and
I Bureau of Clinician Recruitment and Services
cost effective pharmacy services; Poison
(BCRS).
BCRS oversees the National
Control Centers, which fund poison con-
Health Service Corps, which provides
trol centers throughout the U.S. as well
scholarships and loan repayment to those
as provide a toll-free number and media
who agree to serve as primary care
campaign; the National Vaccine Injury
providers in health professional shortage
Compensation Program, which oversees
areas; and Nursing Scholarship and Loan
compensation for those who have vac-
Repayment, which offers repayment to
cine-associated injuries and/or deaths;
nurses if they serve no less than two years
and Healthcare-Related Facilities, which
in an Indian Health Service health cen-
provides for construction and renovation
ter, Native Hawaiian health center, pub-
of health facilities throughout the U.S.
lic hospital, migrant health center, or
rural health clinic.
I Maternal and Child Health (MCH) Bureau.
This bureau implements the Maternal
I HIV/AIDS Bureau. This Bureau oversees
and Child Health (MCH) Block Grant.
the Ryan White HIV/AIDS Programs.
The block grant sends money to the
After Medicaid, Ryan White programs are
states to establish preventive and primary
the largest federal financial commitment
care networks for pregnant women,
for the care and treatment of people liv-
mothers, children, infants, and adoles-
ing with HIV/AIDS. These programs re-
cents. MCH provides prenatal care, im-
imburse for HIV-related pharmaceuticals,
munizations, comprehensive health care,
provide community-based services treat-
home visits, and access to dental care.
ment and support services, case manage-
ment, substance abuse treatment, mental
I Other Offices. In addition to these Bu-
health, and nutritional services.
reaus, there are also several offices that
oversee information technology and
I Healthcare Systems Bureau. This bureau
grant and management implemen-
oversees organ donation and transplan-
tation, as well as the Office of Rural
tation, which supports a registry and net-
Health Policy, which conducts rural
work to match donors and potential
health research and provides technical
recipients, and provides education about
assistance to state offices of rural health.
organ donation; the National Cord Blood
76
HRSA FUNDING HISTORY
HRSA
FY 2005
FY 2006
FY 2007
FY 2008
FY 2009
FY 05
FY 2009
Major Program
Actual
Actual
Actual
Enacted
CR
Inflated
CR+/- Inflated
to $ 08
to $08
Total Program Level
$6,854*
$6,119 $6,446 $6,916 $6,916 $7,689
($773)
Primary Care
$1,754 $1,803 $2,006 $2,083 $2,083 $1,968
$115
Health Centers
$1,734
$1,785
$1,988
$2,065
$2,065
$1,945
$120
Free Clinics Medical Malpractice Coverage
$0
$0
$0
$0
$0
Hansen’s Disease Services Program
$20
$18
$16
$16
$16
$22
($6)
Clinician Recruitment and Services
$131 $125 $158 $155 $155 $147
$8
National Health Service Corps
$131
$125
$126
$123
$123
$147
($24)
Nurse Loan Repayment & Scholarship Program
$31
$31
$31
Loan Repayment/Faculty Fellowships
$1
$1
$1
Health Professions
$751 $592 $599 $623 $623 $842
($219)
Health Professions Training Activities
$252
$145
Centers of Excellence
$12
$13
$13
Scholarships for Disadvantaged Students
$47
$47
$46
$46
$53
($7)
Health Careers Opportunity Program
$4
$10
$10
Training in Primary Care Medicine and Dentistry
$49
$48
$48
Area Health Education Centers
$29
$28
$28
Geriatric Programs
$32
$31
$31
Allied Health and Other Disciplines
$4
$9
$9
Public Health/ Preventive Medicine
$8
$8
$8
Nurse Training/Workforce
Development Programs
$151
$150
$119
$126
$126
$169
($43)
Patient Navigator
$3
$3
Children’s Hospitals Graduate Medical Education
$301
$297
$297
$302
$302
$338
($36)
Maternal & Child Health
$869 $835 $838 $849 $849 $975
($126)
MCH Block Grant
$724
$693
$693
$666
$666
$812
($146)
Autism and Other Developmental Disorders
$36
$36
Traumatic Brain Injury
$9
$9
$9
$9
$9
$10
($1)
Universal Newborn Hearing Screening/
Trauma/ Sickle Cell
$13
$12
$12
$15
$15
$15
$0
EMS for Children
$20
$20
$20
$19
$19
$22
($3)
Healthy Start
$103
$101
$102
$100
$100
$116
($16)
Family-to-Family Health Information Centers
$0
$0
$3
$4
$4
Ryan White HIV/AIDS Activities
$2,073 $2,061 $2,138 $2,167 $2,167 $2,325
($158)
Health Care Systems
$83 $75 $75 $82 $82 $93
($11)
Organ Transplantation
$24
$23
$23
$23
$23
$27
($4)
Cord Blood Stem Cell Bank
$10
$4
$4
$9
$9
$11
($2)
Bone Marrow Donor Registry
$25
$25
$25
$24
$24
$28
($4)
Poison Control
$24
$23
$23
$27
$27
$27
$0
Rural Health
$153
$168
$168
$175
$175
$172
($3)
Black Lung/Radiation Exposure Compensation
$8
$8
$6
$6
$6
$9
$3
Other
$1,041 $458 $463 $783 $783 $1,168
($385)
Healthy Community Access Program
$83
Office of Pharmacy Affairs (340B Program)
$0
$0
Family Planning
$286
$283
$283
$300
$300
$321
($21)
Telehealth
$4 $7 $7 $7 $7 $5
$3
Public Health Improvement
(Facilities and Other Projects)
$304
$304
Health Care Facilities/Other Improvement Projects
$483
State Planning Grants
$11
Program Management
$154
$151
$146
$141
$141
$173
($32)
Vaccine Injury Compensation Program
$4
$5
$5
HEAL Direct Operations
$3
$3
$3
National Practitioner Data Bank (User Fee)
$16
$13
$16
$19
$19
$18
$1
Health Integrity & Protection Data Banks (User Fee)
$4
$4
$4
$4
$4
$4
$0
Bioterrorism (BT)
$515
* $515 for BT appropriated in FY 2005 was backed out of the agency total for FY 2005 since that program has since been
transferred to the Office of the Assistant Secretary for Preparedness and Response and is reflected in that budget.
Source: HHS Budget in Brief - FY 2009, 2008, 2007
77
INDIAN HEALTH SERVICE (IHS)
MISSION
To raise the physical, mental, social, and spiritual health of American Indians and
Alaska Natives.
IHS ORGANIZATIONAL CHART128
Office of
Director
Office of
Tribal Self-
Urban
Governance
Deputy Director
Indian
Health
Deputy Director for Indian
Programs
Health Policy
Office of
Deputy Director for
Tribal
Management Operations
Programs
Office of
Office of
Office of
Office of
Office of
Office of
Office of
Clinical and
Information
Public
Resource
Finance and
Management
Environmental
Preventative
Technology
Health
Access and
Accounting
Services
Health
Services
Support
Partnerships
Engineering
Aberdeen
Alaska Area
Albuquerque
Bemidji
Billings
California
Nashville
Area Office
Office
Area Office
Area Office
Area Office
Area Office
Area Office
Navajo Area
Oklahoma
Phoenix
Portland
Tucson Area
Office
Area Office
Area Office
Area Office
Office
78
O R G A N I Z AT I O N A N D M A J O R P R O G R A M S 1 2 9
Services are delivered in the following ways:
viding medical care, which includes sub-
I
stance abuse prevention and treatment, to
Direct Health Care Services. Health services
building sanitation systems to provide
are delivered through area offices dis-
water and waste disposal for homes. In re-
persed throughout the nation, as well as
cent years, there has been an emphasis on
163 IHS and tribally managed units.
health prevention initiatives such as health
I Tribally-Operated Health Care Services. Serv-
education and immunizations.
ices are provided through compacts
L The largest program that is funded by
which represent 325 tribes.
the IHS is clinical services. The pro-
I Urban Indian Health Care Services and Re-
gram traditionally receives an annual ap-
source Centers. These services are deliv-
propriation of about $3 billion while
ered through community health and
preventive health receives $140 million.
comprehensive health care centers.
I Facilities. This oversees construction, en-
IHS programs are divided between “Ser-
vironmental health support, mainte-
vices” and “Facilities:”
nance and improvement, and medical
I
equipment.
Services. This includes clinical and pre-
ventive health services ranging from pro-
IHS FUNDING HISTORY
Indian Health Services
FY 2005
FY 2006
FY 2007
FY 2008
FY 2009
FY 05
FY 2009
Major Program
Actual
Actual
Actual
Enacted
CR
Inflated
CR+/- Inflated
to $ 08
to $08
Total Program Level
$3,813 $3,883 $4,103 $4,282 $4,282 $4,277
$5
Services:
$3,418 $3,523 $3,736 $3,901 $3,901 $3,834
$67
Clinical Services
$2,762
$2,857
$3,056
$3,213
$3,213
$3,098
$115
Contract Health Services
$498
$517
$543
$579
$579
$559
$20
Preventive Health
$110
$117
$123
$128
$128
$123
$5
Contract Support Costs
$264
$265
$270
$270
$267
$296
($29)
Tribal Management/Self-Governance
$8
$8
$8
$8
$8
$9
($1)
Urban Health
$32
$33
$34
$35
$35
$36
($1)
Indian Health Professions
$30
$31
$31
$36
$36
$34
$2
Direct Operations
$62
$62
$64
$64
$64
$70
($6)
Diabetes Grants
$150
$150
$150
$150
$150
$168
($18)
Facilities:
$395 $360 $368 $381 $381 $443
($62)
Health Care Facilities Construction
$89
$38
$26
$37
$37
$100
($63)
Sanitation Facilities Construction
$92
$92
$94
$94
$94
$103
($9)
Facilities & Environmental Health Support
$142
$151
$165
$170
$170
$159
$11
Maintenance & Improvement
$55
$58
$61
$59
$59
$62
($3)
Medical Equipment
$17
$21
$22
$21
$21
$19
$2
Source: HHS Budget in Brief -- FY 2009, 2008, 2007
79
NATIONAL INSTITUTES OF HEALTH (NIH)
MISSION
Science in pursuit of fundamental knowledge about the nature and behavior of living
systems and the application of that knowledge to extend healthy life and reduce the
burdens of illness and disability.
NIH ORGANIZATIONAL CHART130
NIH
Office of the Director Staff Offices:
Office of Director
Extramural Research, Intramural Research;
Program Office:
Management/CFO; Science Policy; Communication and Public
Division of Program
Director
Liaison; Equal Opportunity and Diversity Management;
Coordination, Planning
Legislative Policy and Analysis; Executive Office; Office of the
and Strategic Initiatives
Ombudsman; NIH Ethics Office; Office of the Chief Informational
Officer
National
National Eye
National
National
National
National
National
National Institute
Cancer Center
Institute
Heart, Lung
Human
Institute on
Institute on
Institute of
of Arthritis and
and Blood
Genome
Aging
Alcohol
Allergy and
Musculoskeletal and
Institute
Research
Abuse and
Infectious
Skin Diseases
Institute
Alcoholism
Diseases
National
National
National Institute
National
National
National
National
National
Institute of
Institute of
on Deafness and
Institute of
Institute of
Institute on
Institute of
Institute of
Biomedical
Child Health and
Other
Dental and
Diabetes and
Drug Abuse
Environmental
General
Imaging and
Human
Communication
Craniofacial
Digestive
Health Sciences
Medical
Bioengineering
Development
Disorders
Research
Kidney Diseases
Services
National
National
National
National
John E. Fogarty
National Center for
National
National
Institute of
Institute of
Institute of
Library of
International
Complimentary
Center on
Center for
Mental Health
Neurological
Nursing
Medicine
Center for the
and Alternative
Minority
Research
Disorders and
Research
Advanced Study in
Medicine
Health and
Resources
Stroke
the Health
Disparities
Sciences
Clinical Center
Center for Information
Center for Scientific
Technology
Review
O R G A N I Z AT I O N A N D M A J O R P R O G R A M S
I NIH has 27 institutes and centers. Each
ship, research management and sup-
institute and center has its own individual
port, facilities operation.
charge and agenda.
I Extramural (External) Research: About 80
L The three institutes that annually re-
percent of NIH’s budget supports research
ceive the most funding are the Na-
initiatives of more than 300,000 scientists
tional Cancer Institute, the National
and researchers who are affiliated with
Heart, Lung and Blood Institute, and
over 3,000 universities, medical schools,
the National Institute of Allergy and
hospitals,and other research facilities.
Infectious Disease.
I Intramural (Internal) Research: About 11
I The Office of the NIH Director sets over-
percent of NIH funding is allocated for in-
all NIH policy and goals in addition to
house clinical research. Intramural re-
planning, managing, coordinating NIH
search gives the nation the ability to
programs.
respond to immediate health challenges
both in the U.S. and globally.
L An estimated five percent of the NIH
budget is designated for agency leader-
80
NIH FUNDING HISTORY
NIH
FY 2005 FY 2006 FY 2007 FY 2008
FY 09 with
FY 2009
FY 05
FY 2009
Major Program
Actual
Actual
Actual
Enacted Supplemental
CR
Inflated CR+/- Inflated
Approps
to $ 08
to $08
(June 08)
Total Program Level
$28,650 $28,517 $29,137 $29,465 $29,615
$29,465 $32,231 ($2,766)
National Cancer Institute
$4,825
$4,788 $4,795 $4,805
$4,805 $5,428
($623)
National Heart Lung and Blood Institute
$2,941
$2,916 $2,920 $2,922
$2,922 $3,309
($387)
National Institute of Dental and
Craniofacial Research
$392
$389
$389
$390
$390
$441
($51)
National Institute of Diabetes and Digestive
and Kidney Diseases
$1,864
$1,853 $1,855 $1,857
$1,857 $2,097
($240)
National Institute of Neurological
Disorders and Stroke
$1,539
$1,533 $1,535 $1,544
$1,544 $1,731
($187)
National Institute of Allergy and Infectious
Diseases
$4,403 $4,379 $4,366 $4,561
$4,561 $4,953
($392)
National Institute of General Medical
Sciences
$1,944 $1,934 $1,936 $1,936
$1,936 $2,187
($251)
National Institute of Child Health and
Human Development
$1,270
$1,264 $1,254 $1,255
$1,255 $1,429
($174)
National Eye Institute
$669
$666
$667
$667
$667
$753
($86)
National Institute of Environmental
Health Sciences
$725
$715
$721
$720
$720
$816
($96)
National Institute on Aging
$1,052
$1,045 $1,047 $1,047
$1,047 $1,184
($137)
National Institute of Arthritis and
Musculoskeletal and Skin Disorders
$511
$507
$508
$509
$509
$575
($66)
National Institute on Deafness and
Communication Disorders
$394
$393
$394
$394
$394
$443
($49)
National Institute of Mental Health
$1,412
$1,402 $1,404 $1,405
$1,405 $1,589
($184)
National Institute on Drug Abuse
$1,006
$999
$1,000 $1,001
$1,001 $1,132
($131)
National Institute on Alcohol Abuse
and Alchohism
$438
$435
$436
$436
$436
$493
($57)
National Institute of Nursing Research
$138
$137
$137
$137
$137
$155
($18)
National Human Genome Research Institute
$489
$486
$486
$487
$487
$550
($63)
National Institute of Biomedical Imaging
and Bioengineering
$298
$298
$298
$299
$299
$335
($36)
National Center for Research Resources
$1,115
$1,109 $1,144 $1,149
$1,149 $1,254
($105)
National Center for Complementary and
Alternative Medicine
$122
$121
$121
$122
$122
$137
($15)
National Center on Minority Health
and Health Disparities
$196
$195
$199
$200
$200
$221
($21)
Fogarty International Center
$67
$66
$66
$67
$67
$75
($8)
National Library of Medicine
$323
$322
$328
$329
$329
$363
($34)
Office of the Director
$405
$478
$1,047 $1,109
$1,109
$456
$653
Buildings and Facilities
$110
$86
$81
$119
$119
$124
($5)
Source: HHS Budget in Brief - FY 2009, 2008, 2007
81
SUBSTANCE ABUSE AND MENTAL HEALTH
SERVICES ADMINISTRATION (SAMHSA)
MISSION
Improving the quality and availability of prevention, treatment, and
rehabilitative services for those individuals who are at risk for a mental or
substance use disorder(s).
SAMHSA ORGANIZATIONAL CHART131
Administrator
Deputy
Administrator
Office of Applied
Office of Policy,
Office of Program
Studies
Planning and
Services
Budget
Center for Mental
Center for
Center for
Health Services
Substance Abuse
Substance Abuse
Prevention
Treatment
C E N T E R S A N D M A J O R P R O G R A M S
I Center for Mental Health Services. This cen-
alcohol and drug abuse prevention, treat-
ter’s purpose is to improve prevention
ment, and rehabilitation services. Fund-
and mental health treatment services.
ing from these centers is allocated
through a block grant to the states.
L Mental Health Services Block Grant: This
block grant received $421 million in
L Substance Abuse Block Grant: In FY 2008,
FY 2008. It provides funds for mental
the block grant received almost $2 bil-
health services in all 50 states
lion in federal funds. It provides funds
to the states to support alcohol and drug
I Center for Substance Abuse Prevention and
abuse prevention, treatment and reha-
Center for Substance Treatment: These two
biltation services.
centers oversee funding to the states for
82
SAMHSA FUNDING HISTORY
SAMHSA
FY 2005
FY 2006
FY 2007
FY 2008
FY 2009
FY 05
FY 2009
Major Program
Actual
Actual
Actual
Enacted
CR
Inflated
CR+/- Inflated
to $ 08
to $08
Total Program Level
$3,392 $3,324 $3,327 $3,356 $3,356 $3,805
($449)
Substance Abuse:
$2,397
$2,349
$2,350
$2,353
$2,353
$2,689
($336)
Substance Abuse Block Grant
$1,776
$1,757
$1,759
$1,759
$1,759
$1,992
($233)
PROGRAMS OF REGIONAL & NATIONAL SIGNIFICANCE
Treatment
$422 $399 $399 $400 $400 $473
($73)
Prevention
$199 $193 $193 $194 $194 $223
($29)
Mental Health:
$901 $883 $884 $911 $911
$1,011 ($100)
Mental Health Block Grant
$433
$428
$428
$421
$421
$486
($65)
PATH Homeless Formula Grant
$55
$54
$54
$53
$53
$62
($9)
Programs of Regional & National Significance
$274
$263
$263
$299
$299
$307
($8)
Children’s Mental Health Services
$105
$104
$104
$102
$102
$118
($16)
Protection & Advocacy
$34
$34
$34
$35
$35
$38
($3)
Program Management
$94
$92
$93
$93
$93
$105
($12)
Source: HHS Budget in Brief -- FY 2009, 2008, 2007
83
HHS’S OFFICE OF THE SURGEON GENERAL
MISSION
The Office of the Surgeon General, under the direction of the Surgeon General,
oversees the operations of the 6,000-member Commissioned Corps of the U.S. Public
Health Service and provides support for the Surgeon General in the
accomplishment of his other duties.
ORGANIZATION AND MAJOR ACTIVITIES
I The Surgeon General is a part of the Of-
by giving Americans scientific inform-
fice of Public Health and Science, which is
tion on how to improve their health.
composed of “12 core public health offices
I The Surgeon General also oversees the
and the Commissioned Corps.”132
U.S. Public Health Service Commiss ioned
I The Surgeon General’s main purpose is
Corps.
to be the nation’s chief health educator
HHS’S OFFICE OF MINORITY HEALTH
MISSION
To improve and protect the health of racial and ethnic minority populations through
the development of health policies and programs that will eliminate health disparities.
ORGANIZATION AND MAJOR ACTIVITIES
I The Office of Minority Health (OMH) was L Giving support and overseeing the Re-
created in 1986 to “advise the Secretary
gional Minority Health Consultants in
and the Office of Public Health Science
the 10 HHS regional offices
(OPHS) on public health program activi-
L Operating the OMH Resource Center, a
ties affecting American Indians and Alaska
referral service on minority health which
Natives, Asian Americans, Blacks/African
also provides capacity development
Americans, Hispanics/Latinos, Native
through workshops and consultations
Hawaiians, and other Pacific Islanders.”134
L
I
Overseeing the Center for Cultural and
OMH is a part of the Secretary’s office
Linguistic Competence in Health Care,
and is overseen by both a Deputy Assis-
a resource center for health care profes-
tant Secretary and a Deputy Director. Its
sionals; and
responsibilities include:
L
L
Supervising grant initiatives that facili-
Providing staff for the Advisory Com-
tate community linkages and strategies.
mittee on Minority Health;
84
OFFICE OF MINORITY HEALTH ORGANIZATIONAL CHART133
Deputy Assistant
Secretary for
Minority Health
Director of
Minority Health
Division of
Division of Policy
Division of
Information and
and Data
Program
Education
Operations
85
HHS’S ASSISTANT SECRETARY FOR
PREPAREDNESS AND RESPONSE (ASPR)
MISSION
ASPR directs and coordinates HHS’s activities to protect the public from acts
of terrorism and other public health and medical emergencies.
ASPR ORGANIZATIONAL CHART135
Office of the
Assistant Secretary
for Preparedness and
Response
Office of Policy
Office of
Immediate Office/
Biomedical
Office of
and Strategic
Medicine,
Resource,
Advanced
Preparedness and
Planning
Science, and
Planning, and
Research and
Emergency
Public Health
Evaluation
Development
Operations
Authority
ORGANIZATION AND MAJOR ACTIVITIES136
I ASPR was previously known as the Office
spond to domestic and international
of Public Health Emergency Preparedness.
public health and medical threats and
emergencies.”138 It is also responsible
I The Office’s main responsibility is to advise
for logistics for most ASPR programs.
the Secretary on matters of terrorism and
public health and medical emergencies.
L Office of Medicine, Science, and Pub-
lic Health (OMSPH). OMSPH pro-
I ASPR has four offices:
vides “expert medical, scientific, and
L Biomedical Advanced Research and
public health advice on domestic and
Development Authority (BARDA).
international medical preparedness
BARDA provides “coordination and
policies, programs, initiatives, and ac-
expert advice regarding public
tivities.” 139 It is also the liaison with
health medical countermeasures late
national and international health and
stage advanced development and
science organizations.
procurement.”137
L Office of Policy and Strategic Planning
L Office of Preparedness and Emer-
(OPSP). OPSP is “responsible for pol-
gency Operations (OPEO). OPEO de-
icy formulation and coordnation for
velops operational plans, training, and
preparedness and response strategic
exercises “to ensure the preparedness
planning.”140
In partnership with
of the ASPR Office, the Department of
other offices, OPSP also analyzes short
Health and Human Services, the Fed-
and long term policies and Presiden-
eral Government, and the public to re-
tial directives.
86
Section 5
B A C K G R O U N D
R E S O U R C E S
SECTION
5
SECTION
5
Background Resources
HEALTHIER AMERICA: AN AGENDA FOR
MODERNIZING PUBLIC HEALTH
5
S E C T I O N
From Principles to Policies: A National Health and Prevention Strategy
The nation must develop a National Health
Public health agencies at all levels of govern-
and Prevention Strategy that articulates the
ment provide a unique and essential role of
vision of a healthier America. The Secretary
convening and fostering collaboration
of Health and Human Services (HHS), on
among all sectors of society to consider the
behalf of the President, should be charged
health consequences of policy decisions.
with developing this plan in a collaborative
I The federal government must play a
process. The strategy must:
leadership role and serve as a catalyst
I Incorporate increased prevention efforts
for change, driving fundamental change and
into health care services and finance;
bold initiatives. The federal role includes: fi-
I
nancial and technical assistance for state and
Strengthen collaboration among public
agencies and the private sector; and
local health agencies and best practice infor-
mation for designing and implementing ef-
I Ensure essential prevention services are
fective prevention programs.
delivered nationwide in accordance with
minimum national standards.
L In America, every individual, family,
and community has a right to the same
The National Health and Prevention Strategy
level and quality of services to help
should include as core operating principles:
them be healthy, regardless of who they
(1) efficient deployment of resources to pre-
are or where they live -- a right only the
vent illness; (2) accountability for outcomes;
federal government can ensure.
and (3) recognition that helping people be
healthy requires addressing the entire social
I States and communities are the front lines
context, including geographic, economic,
of protecting the public’s health. Public
racial, and ethnic disparities.
health practitioners, with leadership from
governmental partners, must understand
Implementation of the National Health and
the particular health concerns of each
Prevention Strategy should include per-
community and mobilize resources to ad-
formance standards, outcome measures, and
dress them. They must focus on, track,
accreditation procedures for delivery of es-
and prevent disease; provide childhood
sential prevention services by federal, state,
and adult vaccinations; prevent and re-
and local agencies.
spond to threats of bioterrorism and dis-
In order to achieve these goals, everyone
ease; prevent trauma and injuries; ensure
must participate and work together.
food and water safety; and protect against
environmental health hazards.
Every individual, every business, every com-
munity, and every level of the health system,
I Businesses must provide employees with
including health care providers and public
health promotion and disease prevention
health agencies at the federal, state, and local
benefits and healthy work environments and
levels of government, must take shared re-
conditions. They should work to create pub-
sponsibility for protecting the health of fam-
lic-private partnerships to ensure healthier
ilies and communities.141
communities for their workers and their
87
families. Corporate leaders also need to con-
portant to student achievement as the aca-
tinue to sound the alarm on how an un-
demic standards in the Act.
healthy workforce affects bottom-lines.
I Non-health agencies and community or-
I Schools must build physical and health ed-
ganizations must communicate and col-
ucation into the curriculum. The federal
laborate with leaders at all levels of
government should make it easier for states
government. Community organizations
and localities to do so by writing physical
are uniquely positioned to reach certain
and health education requirements into the
sectors of the community that government
No Child Left Behind Act -- these are as im-
has traditionally had difficulty reaching.
The following are key components of a National Health and Prevention Strategy.
1. LEADERSHIP AND ACCOUNTABILITY: A HEIGHTENED ROLE
FOR THE SECRETARY OF HEALTH AND HUMAN SERVICES
Currently, there is no clear focal point within
persons representing the general public as
the federal government for national leader-
the vehicle for wide collaboration in devel-
ship on wellness and prevention. Within the
oping and overseeing implementation of
federal government, one individual, the U.S.
the National Strategy.
Secretary of Health and Human Services
I Implementing the National Strategy, in-
(HHS), should have the responsibility (on be-
cluding making available sufficient re-
half of the President) to convene and facili-
sources, based on widely agreed upon
tate coordinated planning and investment in
performance standards, outcome meas-
programming and research across all federal
ures, and accreditation procedures to en-
agencies, and hold them accountable for pre-
sure accountability for effective use of
venting disease and empowering every person
resources in the delivery of essential well-
to live a healthier life.
ness and prevention services by federal,
The specific responsibilities of the HHS
state, and local agencies.
Secretary would include:
I Undertaking regular and transparent as-
I Establishing and leading an Inter
-
sessments of progress in meeting the per-
governmental Public Health Coordinating
formance standards with adequate effort
Council composed of representatives of
and progress by state and local agencies as
state, tribal, and local health directors and
a prerequisite for full federal funding.
2. FUNDING FOR THE NATIONAL HEALTH AND
PREVENTION STRATEGY
The HHS Secretary, in close collaboration
I Collaborating with all elements of the
with all elements of the health system, should
health system to determine the funding re-
determine the funding requirements to im-
quirements to implement the National
plement the National Health and Prevention
Strategy and developing a financing plan
Strategy and develop a financing plan to meet
to meet those requirements, including the
those requirements by:
consistent and continuous delivery of suf-
ficient resources to support services na-
tionwide in accordance with minimum
national standards.
88
I Assuring that the financing plan includes a
I Including reasonable matching and main-
new statutory funding mechanism to pro-
tenance-of-effort formulas in the financing
vide substantial and stable federal resources
plan that define and ensure adequate fed-
to support state and local prevention pro-
eral, state, and local funding of wellness
grams, as well as the provision of necessary
and prevention efforts.
technical assistance to states and localities to
implement the National Strategy and meet
their local responsibilities.
3. TOOLS AND KNOWLEDGE NEEDED FOR IMPLEMENTING
THE NATIONAL HEALTH AND PREVENTION STRATEGY
As part of the National Health and Prevention
with other federal, state, and local govern-
Strategy, the federal government should de-
mental and non-governmental partners,
velop and operate a comprehensive informa-
and to take advantage of the potential of
tion and assessment system to provide public
electronic health records to produce more
agencies and private actors the best possible in-
robust and timely information that can be
formation about: (1) the health status of pop-
used to understand chronic, infectious, and
ulations throughout the country; (2) priorities
environmental health problems, and detect
for investment in wellness and prevention; and
emerging problems.
(3) the effectiveness of proposed and imple-
I The federal government should adopt a
mented interventions in preventing adverse
philosophy and practice of transparency
health outcomes. In order to achieve this out-
and commit itself to the rapid sharing of
come, the strategy should require that:
health information with all public and pri-
I The U.S. Centers for Disease Control and
vate partners in the health system, consis-
Prevention’s (CDC) disease surveillance sys-
tent with legitimate privacy and national
tems be modernized to better share data
security concerns.
4. ELIMINATE HEALTH DISPARITIES
The social determinants of health include ed-
I Invest in the data collection and analysis re-
ucation, income, housing conditions, occupa-
quired to understand the basis for health
tion, race, ethnicity, social connectedness, and
disparities and develop and fund effective
place of residence. To address health dispari-
interventions to reduce them; and
ties, the federal government should:
I Develop a priority list of significant socioe-
I Provide leadership to make eliminating
conomic, racial, and ethnic disparities as-
health disparities a central aim of both the
sociated with the major chronic diseases;
National Health and Prevention Strategy
develop specific goals, strategies, and ac-
and the public health system itself;
tion plans to reduce them; and report an-
nually on progress and obstacles.
89
5. CHRONIC DISEASE
Many chronic diseases are, to a substantial de-
Preventing Tobacco Use
gree, preventable. However, many of the
I Problem: Tobacco remains the single most
known strategies to help people prevent
preventable cause of death and disease in
chronic disease are not receiving the resources
the United States, and despite recent
or prioritization needed to be effectively im-
progress, kills more than 400,000 people
plemented. The federal government should
annually.142
take action to address specific chronic disease
I Objective: The federal government should
problems, including the following:
provide stronger leadership to reduce smok-
Financing Prevention of Chronic Disease
ing and its health consequences by fully fund-
I
ing comprehensive state tobacco control
Problem: The health care finance system
programs, raising taxes on tobacco, and em-
shortchanges the funding of preventive
powering the Food and Drug Administration
health care services, such as obesity coun-
(FDA) to regulate tobacco products. Local
seling, early screening, and immunization.
and state governments have already shown
I Objective: Comprehensive coverage of pre-
strong leadership in this area.
ventive health care services should be in-
cluded in all federal- and state-financed
Reducing Obesity, Overweight, and Physi-
health insurance programs and be a cen-
cal Inactivity
tral aim of broader health care finance re-
I Problem: Though obesity, overweight, and
form. Additionally, coverage for such
physical inactivity are closely linked with the
services should be provided without a co-
most common threats to longevity and
pay or deductible.
quality of life, including cardiovascular dis-
ease and stroke, diabetes, hypertension,
Screening for Early Detection and Prevention
and some cancers, they are not a priority at
I Problem: Health screening is a proven and
the national level and a coherent, effective
effective way to reduce the health burden
prevention strategy is lacking.
of chronic disease, but it is not practiced
I Objective: The federal government should
to the extent it must be to achieve its full
engage all stakeholders in a concerted na-
potential.
tional effort to provide individuals the tools
I Objective: The federal government, in col-
they need to reduce obesity, overweight,
laboration with state and local health offi-
and physical inactivity, and their health con-
cials, should lead a national campaign to
sequences. This effort would include pro-
increase screening for major chronic dis-
motion of expanded physical and health
eases, focusing on such high-priority pre-
education, as well as healthier nutrition poli-
vention opportunities as mammography
cies, in schools, day care, and after-school
screening, blood pressure and cholesterol
settings; readier access to wellness programs
testing, and colorectal cancer screening. As-
in the workplace and elsewhere; a healthier
sociated with any campaign to increase
built environment; better information in
screening must be assurances that those
the marketplace about the caloric and nu-
needing treatment are linked to care.
tritional content of foods; and changes in
Changes in laws, regulations, contracts, and
laws, regulations, rules, and reporting.
reporting requirements will be necessary.
90
6. ENVIRONMENTAL HEALTH
The interaction between human beings and
Building Knowledge of Environmental
chemical, biological, and physical hazards in
Health Problems and Solutions
the natural and man-made environment is
I Problem: The establishment at CDC of the
one of the primary determinants of health
National Environmental Public Health
and the cause of increased risks of cancer,
Tracking Program was an important step in
birth defects, childhood development prob-
the right direction, but health agencies, busi-
lems, asthma, and neurological disease, all of
nesses, and individual citizens still lack the
which inflict significant suffering and eco-
knowledge they need to understand and pre-
nomic costs reaching billions of dollars.
vent environmental health problems.
At the federal level, environmental risks are
I Objective: The federal government should
now addressed in a piecemeal fashion by nu-
build on the Tracking Program and its many
merous agencies, without a clear focal point
other disease surveillance and biomonitor-
for leadership, development of the knowledge
ing programs and transform them into a 21st
needed to understand risks, and action to re-
century system for detecting environmental
duce risks. As a result, the federal government
hazards -- a system capable of discovering
is falling far short of what it could do to protect
hazards in real time and making the infor-
people from environmental hazards and pre-
mation available promptly, in usable form to
vent disease, disability, and death. Addition-
all who need it to protect health. Addition-
ally, state and local governmental agencies are
ally, a broader research agenda is needed to
not able to work effectively and in a coordi-
improve our understanding of environmen-
nated fashion with the federal government to
tal risks to health.
protect their residents. Actions in the follow-
ing areas will help address these problems.
Taking Action to Protect Health
I Problem: The federal government is chroni-
Providing Leadership on
cally slow in acting to address environmen-
Environmental Health
tal health problems.
I Problem: The lack of a focal point for na-
tional leadership on environmental health
I Objective: The President’s environmental
undermines the effectiveness and account-
health leader, in collaboration with federal
ability of the federal effort, as well as coor-
agencies and their state and local counter-
dinated efforts among federal, state, and
parts, should identify the ten most signifi-
local governments, and impedes progress in
cant environmental health hazards and
reducing risks and protecting the health of
opportunities to reduce risk, set specific
Americans.
goals, and establish action plans for reduc-
ing those risks, and report biennially on
I Objective: The federal government should
progress and obstacles. Adequate funding
strengthen its leadership by designating a
must accompany these actions.
single official as the President’s environ-
mental health leader with responsibility to
Addressing the Built Environment
develop an overall environmental health
I Problem: Conditions in the built environ-
strategy (including measures of progress),
ment -- including homes, workplaces,
coordinate among agencies on imple-
transportation systems, playgrounds, and
mentation of the strategy, and report to
other public spaces -- profoundly affect
Congress and the public biennially on the
rates of illness and injury and levels of
state of environmental health and the
stress among children and adults in ways
progress achieved.
that are just beginning to be understood.
91
I Objective: Bring public health depart-
community together to prevent and solve
ments, urban planners, transportation ex-
environmental health problems, and pro-
perts, manufacturers, developers, and the
vide adequate funding to do so.
7. INFECTIOUS DISEASE
The HIV/AIDS epidemic that emerged in
detection and information technologies,
the 1980’s, and the present, very real threat
such as electronic lab reporting and elec-
of a devastating pandemic influenza remind
tronic health records to deliver high-qual-
us that infectious disease remains a major
ity information on a timely basis to people
health problem in the U.S., not to mention
who can use it to prevent disease.
having three infectious diseases -- influenza,
pneumonia, and septicemia -- still among the
Childhood and Adult Immunization
top ten causes of death. We know through
I Problem: Vaccination is among the most ef-
long experience what works to prevent in-
fective tools to prevent infectious disease, but
fectious disease, and we have many of the
many children and adults do not receive rec-
tools that are needed, such as surveillance,
ommended vaccinations due in part to in-
immunization, and antibiotics, but we have
creased costs and barriers to access.
neither fully deployed the tools we have, nor
I Objective: The federal government should
invested sufficiently, to keep up with the dy-
fully fund all of CDC’s immunization pro-
namic and persistent problem of infectious
grams and take other actions needed to
disease in our globalized society.
improve access and motivate people to
It is critical that the federal government act
seek vaccination, with the goal of achiev-
decisively to improve the prevention and
ing 100 percent vaccination rates among
containment of infectious disease by bolster-
all Americans.
ing its efforts in at least three areas.
Pandemic Influenza Preparedness
Early Detection of Outbreaks and Emerg-
I Problem: Many experts consider a future in-
ing Infectious Diseases
fluenza pandemic to be inevitable and pan-
I Problem: CDC coordinates and supports
demic preparedness to be essential to the
more than 100 national surveillance sys-
nation’s health and economic well-being.
tems that are implemented primarily by
This requires sustained federal leadership
state and local health officials, and that are
and strategic investment of adequate re-
characterized by poor sharing of informa-
sources to meet the preparedness need.
tion among the systems and delays in re-
I Objective: The federal government should
porting results to those who need the
update as needed, fully fund, and promptly
information in a timely fashion.143 These
carry out the President’s National Strategy
systems are also characterized by inade-
for Pandemic Influenza Implementation
quate funding, making it difficult to pro-
Plan, and it should step up its investment in
tect the public’s health.
vaccine and anti-viral drug development
I Objective: The Secretary of HHS, working
and supply to be able to more rapidly vac-
through CDC and in close partnership
cinate and treat the population should a
with state and local health departments,
pandemic occur. The federal government
should drive the integration and modern-
should also ensure that state and local gov-
ization of infectious disease surveillance to
ernments have the capacity to deliver these
take advantage of important new disease
countermeasures.
92
8. HEALTH DISASTER PREPAREDNESS
The September 11 attacks, Hurricane Kat-
sure the needed coordination and integra-
rina, and the ongoing threat of bioterrorism
tion across all the agencies that have a role
make clear the need to be prepared for the
to play.
public health consequences of extraordinary
events. Failure to prepare can turn a health
Surge Capacity and the Workforce
crisis into a health catastrophe resulting in
I Problem: Emergencies place great strain
human suffering and economic losses that
on an already over-stretched public health
could have been avoided.
workforce, which, due to chronic under-
funding, struggles to meet routine public
Congress and the President have recognized
health needs and remains in most locali-
this fact, as evidenced by the passage of the
ties ill-prepared to respond to major
Public Health Security and Bioterrorism Act
health disasters.
of 2002 and the Pandemic and All-Hazards
Preparedness Act of 2006 (“All-Hazards
I Objective: The federal government should
Act”). The challenge now is to ensure that
strengthen the regular public health work-
federal, state, and local preparedness efforts
force by fully funding and implementing
are continuously and adequately funded and
the workforce enhancement provisions of
well implemented, with particular attention
the All-Hazards Act and provide for a sup-
to preparing the public health workforce, de-
plemental, volunteer workforce trained to
veloping and stocking needed technology
assist in large-scale emergencies by en-
and equipment, and fully involving all levels
hancing recruitment, training, and reten-
of government and all elements of the com-
tion of volunteer medical personnel in the
munity, in the context of clearly defined per-
National Disaster Medical System and the
formance standards, so that all Americans
Medical Reserve Corps.
are equally protected.
Technology and Equipment
Leadership and Accountability
I Problem: Early detection and containment
I Problem: In our highly decentralized sys-
of disease outbreaks associated with acts of
tem of federal, state, and local health
bioterrorism or natural disaster is critical to
agencies, national leadership and action
minimizing the harm done to health and
are essential to ensure disaster and emer-
the economy, but demands increasingly so-
gency threats are well-assessed and stan-
phisticated surveillance strategies, including
dards for preparedness are set. As
improved diagnostics, more real-time re-
Hurricane Katrina illustrated, this is not al-
porting systems, and greater coordination
ways the case.
and computer connectivity, as well as effec-
I
tive countermeasures, such as vaccines, and
Objective: Designate a single official within
treatment drugs.
HHS to be responsible, accountable, and
fully empowered to plan and coordinate
I Objective: The federal government should
implementation of the National Health Se-
fully fund and implement the Biomedical
curity Strategy called for in the All-Hazards
Advanced Research and Development Au-
Act. This official should either perform or
thority (BARDA), as authorized in the All-
oversee all the preparedness-related activi-
Hazards Act, and bolster the Strategic
ties of the new Assistant Secretary for Pre-
National Stockpile of medicines and equip-
paredness and Response, the Assistant
ment needed to respond to emergencies
Secretary of Health, and all other compo-
through research, development, produc-
nents of HHS. Further, he or she must en-
tion, and acquisition of needed items.
93
Involving the Community in Preparedness Planning
I Problem: Emergency preparedness requires
I Objective: The federal government should
the attention and involvement of thousands
make active community involvement a cen-
of government agencies at all levels and
tral pillar of its preparedness strategy and
working relationships with a wide array of
planning process and support the efforts
business and community groups, but this re-
of states and localities to develop innova-
quires new and more effective means of
tive methods for involving and collaborat-
communication and outreach and a partic-
ing with all segments of the community.
ular focus on vulnerable populations.
CONCLUSION
With a renewed commitment to prevention
active participation of all stakeholders and
and a revitalized public health system, Amer-
sustained leadership and action at the fed-
ica can fulfill the vision of becoming the
eral level. This document offers a template
healthiest nation in the world, reaping enor-
for federal leadership and action and for the
mous benefits in personal well-being and
long-overdue moment when wellness and
economic security. Though this vision will ul-
prevention are placed at the center of Amer-
timately be achieved at the individual, fam-
ica’s health strategy.
ily, and community level, it requires the
94
Agenda for Modernizing
Public Health
1
A P P E N D I X
ACTING TO PREVENT CHRONIC DISEASE – A
WELLNESS AGENDA FOR AMERICA’S FAMILIES
AND COMMUNITIES
Background and Need for Action
In sheer magnitude of impact, chronic disease
ing local economies and the competitiveness
is America’s number one health problem, en-
of American business. In one state alone, In-
compassing five of our top six causes of death -
diana, the cost to employers of tobacco-re-
- heart disease, cancer, stroke, chronic
lated illness is estimated to have exceeded
obstructive pulmonary disease, and diabetes.
$100 billion in new business investment and
In addition, Alzheimer’s disease and other
175,000 jobs, as companies seek to locate
chronic conditions affecting mental health
where health costs are lower, often meaning
contribute significantly to the nation’s chronic
overseas.151
disease burden. All together, chronic disease
For all the destruction caused by chronic dis-
today accounts for about 70 percent of all
ease, to a substantial degree, most are pre-
deaths in the United States, inflicts untold dis-
ventable. While genetics and uncontrollable
ability and suffering, and consumes three-quar-
environmental factors clearly play a role, per-
ters of the $1.7 trillion our nation now spends
sonal choices, individual lifestyle decisions,
on health care each year. 144, 145, 146, 147, 148
the man-made social environment, and the
The effects of chronic disease have a pro-
failure to implement known prevention meas-
found impact on America’s families and com-
ures are among the highest risk factors of
munities. If current trends continue, it is
chronic disease. For example, smoking, the
estimated that one in three U.S. children will
single most preventable cause of death and
become diabetic and be at increased risk of
disease in the U.S., causes 440,000 premature
nerve and kidney damage, heart disease, and
deaths annually.152 The recent success of
blindness.149 Breast cancer now strikes almost
smoking cessation programs demonstrate that
180,000 women annually and kills 40,000.150
rates of smoking, especially among the young,
Research is also beginning to indicate that car-
can be reduced, thus saving lives.
diovascular disease and diabetes may be risk
Despite these well-recognized facts, our na-
factors for Alzheimer’s, a disease that already
tion’s health system and policy debates con-
cripples so many Americans. And, as it stands
tinue to focus principally on the delivery and
today, the toll taken by chronic disease will
financing of treatment services; not the fact
only grow as our population ages.
that America today invests less than 5 percent
As chronic disease robs more Americans of
of its resources in chronic disease prevention
their lives (and their quality of life), it is also
activities. At the state level, however, this is
wreaking havoc on our nation’s economy.
beginning to change.
Today, it is claiming an ever-growing share of
In direct response to the economic impact
health care spending and also poses a threat
chronic disease is having in Indiana, the state’s
to the future of Medicare. Even more, the
governor has launched the innovative IN-
soaring costs of chronic disease are damag-
95
Shape Indiana program to combat obesity and
through the Secretary of Health and Human
smoking.153 Similarly, California and other
Services (HHS), and with the full support of
states that are moving toward universal health
Congress, should lead, develop, and imple-
coverage are recognizing that wellness and
ment a National Health and Prevention Strat-
prevention are essential elements of any eco-
egy (National Strategy).
nomically sustainable health strategy. Never-
A successful National Strategy would bridge
theless, the scant attention given to prevention
the growing divide between the delivery of in-
persists at the federal level. As a result, Amer-
dividual health care services and the efforts of
ica is missing a great opportunity to improve
public health agencies to protect the popula-
both the well-being of our citizens and our
tion as a whole. Achieving this would require
economy by delaying the onset of, or prevent-
integrating and bolstering the wellness and
ing altogether, disabling and often fatal
prevention efforts of all federal and state
chronic disease.
health services. This, in turn, would require
Ultimately, the success of wellness and preven-
new funding mechanisms as well as the cre-
tion initiatives is determined by individuals,
ation of additional capacity for information
families, and their communities. However, the
collection and assessment. However, govern-
federal government can move wellness and
ment action alone will not be sufficient. To
prevention to the center of our nation’s health
achieve its goals, a National Strategy must also
strategy and help ensure that Americans have
involve schools, businesses, community
the knowledge they need to lead healthier lives.
groups, and other stakeholders.
To achieve this, the federal government, acting
Financing Prevention
Investing resources in wellness and prevention
programs that strengthen the capacity of pub-
is the critical first step. There is substantial ev-
lic health departments and their community
idence that prevention programs can work to
partners to deliver prevention services.
reduce the risk of chronic disease and the as-
I Include comprehensive preventive health
sociated burden of suffering, disability, and
services, such as obesity, nutrition, and phys-
drain on the health finance system. As noted,
ical activity counseling, and smoking cessa-
our nation invests relatively little to develop
tion programs, in federal employee health
and implement population-based, chronic dis-
insurance programs and in Medicaid and
ease prevention programs, and we do not have
Medicare. Encourage business and non-
adequate mechanisms to cover the costs of
profit organizations to do the same through
wellness and preventive health care programs
tax incentives or other means.
for individuals. The federal government
should take the following actions to help ad-
I Require that coverage of preventive services
dress these needs:
with no co-pays or deductibles be a central
I
objective of any federal reform of the
Substantially increase at the federal level the
health care finance system.
conduct and dissemination of systematic re-
search and analysis to support effective
I Encourage states that are moving toward
chronic disease prevention programs and set
universal health coverage to provide for pre-
priorities for prevention efforts, particularly
ventive services as part of the health care de-
those that operate at the community level.
livery system and through increased support
I
of the wellness and prevention programs
Increase funding through the Centers for Dis-
provided by public health agencies.
ease Control and Prevention (CDC) of high-
priority, effective state and local prevention
96
Screening for Early Detection and Prevention
CDC has identified health screening as a vital
I Ensure full and effective delivery of Med-
factor and proven-effective intervention for
icaid’s child health component, known as
preventing and reducing the burden of
the Early and Periodic Screening, Diagno-
chronic disease. For this reason, the federal
sis, and Treatment (EPSDT) program, and
government should take the following steps
provide assurance of similar services for
to increase screening:
children served by the State Children’s
I
Health Insurance Program.
Work in close collaboration with state and
local health officials to develop a national
I Develop incentives through regulation
plan to increase screening for the major
and other means for private insurance
chronic diseases, including financing to im-
plans to provide these preventive benefits
prove capacity and access. This plan should
with minimal or no co-pays ordeductibles.
also use social marketing campaigns to en-
I Harness electronic health records to im-
courage mammography screening, blood
prove monitoring of preventive measures in
pressure, blood cholesterol, colorectal can-
clinical settings and promote adherence by
cer screening, and other similar measures.
clinicians to preventive services guidelines.
Associated with any campaign to increase
screening must be assurances that those
needing treatment are linked to care.
Preventing Tobacco Use
Tobacco remains the single most preventa-
programs and public education cam-
ble cause of death and disease in the United
paigns, at the minimum level recom-
States and must continue to be a principal
mended by CDC;
public health priority. Immediate action is re-
I Support states and localities in their efforts
quired to:
to enact comprehensive smoke-free work-
I Raise federal and state excise taxes on to-
place laws; and
bacco products to deter smoking and fi-
I Pass legislation empowering and directing
nance tobacco control programs and
the Food and Drug Administration (FDA) to
other public health measures;
regulate tobacco products in order to reduce
I Fully fund all state comprehensive tobacco
their harmful and addictive properties and
control programs, including school-based
prevent their marketing to children.
Addressing Cancer, Heart Disease, and Diabetes
Chronic diseases cause 70 percent of deaths in
limit disease progression and complications
the U.S., and are responsible for three-quar-
that need to be explored by developing and
ters of health care spending.154. 155, 156, 157 In ad-
implementing new programs and policies. For
dition, one in every two men and three women
example:
will develop cancer, and one in four Americans
I Using surveillance systems to monitor and
has heart disease. 158, 159, 160 These and other
ensure quality care is delivered to those liv-
data remind us that, while screening is a nec-
ing with chronic diseases. Two examples of
essary component to prevent additional dis-
use of surveillance to improve care are the
ease burden, we must also respond to the fact
monitoring of hemoglobin A1C levels for di-
that millions of Americans are sick today. Op-
abetes or viral load of HIV.
portunities exist to improve quality of care and
97
Reducing Obesity, Overweight, and Physical Inactivity
Obesity, overweight, and physical inactivity are
I Improvement in the level and quality of in-
closely linked with many of the most common
formation that individuals and educators
and significant threats to longevity and quality
can use to address obesity and promote
of life, including cardiovascular disease and
wellness, including:
stroke, diabetes, hypertension, and some can-
L Updating food labeling to place more
cers. Because of this, reducing obesity and
emphasis on calories;
overweight, and increasing physical activity, is a
high public health priority and merits substan-
L Improving the utility of the Food Pyramid
tially greater effort and attention at the federal
for consumers;
level, including:
L Requiring the posting of nutrition in-
I Better coordination of federally-funded re-
formation on restaurant menus and
search concerning obesity to improve un-
menu boards;
derstanding of its biological, behavioral, and
L Improving and expanding social mar-
social causes and devise workable interven-
keting campaigns to reduce obesity; and
tions to reduce the problem.
I
L Communicating physical activity guide-
Inclusion of obesity and nutrition counseling,
lines to health educators, policy-makers,
as well as screening for obesity and its related
and the general public.
chronic conditions, in federal employee
health insurance programs and Medicaid.
I Ensure that a wellness impact statement be
I
required prior to the construction of new
Expansion of federal government employee
transportation projects, federally-funded
wellness programs and encouragement of
buildings, and other major federal actions
their adoption by private employers.
affecting the built environment.
I Purchase of healthier foods and raising of
I Provide economic incentives to state and
nutrition standards for all government
local health departments and the private
food assistance programs and for food sold
sector to consider the health impact of the
in schools.
built environment and to take action to
I Expansion of physical activity and access to
promote the construction and use of side-
healthy foods in school and after-school
walks, bike trails, playgrounds, and other
settings, and incorporation of nutrition
features of a healthy community.
and physical education into “No Child
Left Behind” requirements.
Eliminating Social Disparities in Chronic Disease Incidence and Prevention
The social determinants of health include
I Cardiovascular disease -- The rate of death
education, income, housing conditions, oc-
from heart disease was approximately 30
cupation, race, ethnicity, social connected-
percent greater in 2000 among African-
ness, and place of residence. The Healthy
American adults than among white adults;
People 2010 process at HHS identified three
death rates from stroke were 40 percent
chronic disease conditions where racial and
higher.
ethnic minorities experience serious I Diabetes -- In 2000, American Indians and
disparities in health access and outcomes:
Alaska natives were 2.6 times more
I Cancer -- African-American women are
likely to have diagnosed diabetes than non-
more than twice as likely to die of cervical
Hispanic Whites; African-Americans were
cancer as white women and more likely to
twice as likely, and Hispanics were 1.9 times
die of breast cancer than women of any
more likely to have diagnosed diabetes.
other racial or ethnic group.
98
These disparities are profoundly significant
tions by both public agencies and actors in
because of the seriousness and high
the private sector.
incidence of the diseases and the large
I Invest in the research, data collection, and
populations involved. To the extent these
analysis required to better understand the
disparities are caused by socioeconomic sta-
basis for health disparities and craft effec-
tus or by differences in access to health serv-
tive interventions to reduce them.
ices based on race and ethnicity, they also
violate fundamental principles of social jus-
I Develop a priority list of significant dispari-
tice. To address these disparities, the federal
ties associated with the major chronic dis-
government should:
eases and develop specific goals, strategies,
I
and action plans to reduce them.
Provide leadership to make reducing
health disparities a central aim of the
I Fund demonstration projects that address
public health system.
the social context of health as a means for
I
improving health outcomes, through CDC’s
Continue to use the Healthy People 2010
REACH Across the U.S. program and other
process to monitor and report on health
locally-based vehicles.
disparities and relevant policies and ac-
CONCLUSION
The enormity of the health and economic
and private, the federal government can pro-
stakes involved in preventing chronic disease
mote a new national vision of wellness and pre-
demands action. Wellness and prevention are
vention, mobilize the needed resources, and
achieved locally, but the transformation re-
generate the knowledge America needs to
quired to make it a national priority requires
sharply reduce the human and economic bur-
federal leadership and resources. Working in
den of chronic disease.
close collaboration with all stakeholders, public
99
Agenda for Modernizing
Public Health
2
A P P E N D I X
HEALTHY ENVIRONMENTS FOR HEALTHY
COMMUNITIES – ACTION TO PROTECT
HEALTH FROM ENVIRONMENTAL HAZARDS
Background and Need for Action
The most fundamental elements of our envi-
tion systems, playgrounds, and other pub-
ronment -- air, food, and water -- are the build-
lic spaces, profoundly affect rates of illness
ing blocks of human life, but they can also
and injury and levels of stress among chil-
jeopardize our health if contaminated with
dren and adults in ways that are just be-
chemical, biological, or other hazards, whether
ginning to be understood.
naturally occurring or man-made. Other ele-
I The co-epidemics of diabetes and obesity are
ments, such as the quality of social and built en-
fueled by adverse environments for healthy
vironments, dangers in the communities where
nutrition and physical activity such as inade-
Americans live, work, and play -- as well as the
quate access to parks, playgrounds, and
changing global climate -- can have equally pro-
trails; long commutes to work and school;
found impacts on the nation’s health. The evi-
and overabundance of fast-food outlets that
dence is staggering:
sell mostly unhealthy food amidst poor ac-
I As much as 80 to 90 percent of cancer cases
cess to outlets for fresh produce.
in the United States are related to such en-
I Income and other socioeconomic factors cre-
vironmental factors as diet, tobacco, alco-
ate disparities in environmental health im-
hol, radiation, infectious agents, and
pacts, as children in sub-standard housing are
chemicals in air, water, and soil.
at greater risk of lead poisoning, and children
I Outdoor air pollutants cause an estimated
who live close to highways are more likely to
50,000 premature deaths and impose
have lung development problems and seri-
health costs estimated to be as high as $50
ous respiratory disease later in life.
billion annually.
I Rising atmospheric carbon dioxide levels
I Childhood asthma has more than doubled
and higher air and water temperatures
over the past two decades, with outdoor and
associated with global warming will likely
indoor air quality being major risk factors.
increase respiratory disease rates, change
I
the distribution and growth of chemical
Mercury, dioxins, and many other persist-
and infectious disease agents in air, water,
ent chemicals continue to contaminate
and soil, and have other currently un-
food, water, and the breast milk of nursing
known and unpredictable impacts on
mothers at levels that pose significant de-
human health risks.
velopmental and other risks to the fetus
and young children.
These and many other environment-related
I
health problems impose significant economic
Food-borne illness associated with bacteria,
costs and threaten the security and well-being
viruses, and other pathogens routinely shake
of every community. However, because envi-
public confidence in the food supply.
ronmental health problems are primarily a
I Conditions in the built environment, in-
product of human activity, they are mostly pre-
cluding homes, work places, transporta-
ventable. But prevention requires a concerted
100
response, and the magnitude of the dangers
and provide the strong leadership required
our nation faces demands decisive action.
to change the status quo when doing so is
necessary to protect health.
Preventing environmental health problems is
no simple task, and it is complicated by the
Adding to the complexity is that our nation
multiplicity of hazardous agents, exposure
has many different regulatory and research
pathways, and potential health outcomes that
agencies at federal, state, and local levels
must be considered. Health officials, private
charged with addressing environmental health
business, and average Americans are con-
problems. The Environmental Protection
fronted by literally thousands of chemical, bio-
Agency (EPA) and CDC play key roles, but
logical, and physical hazards that are present
they are only two of many federal agencies with
in air, water, food, waste, at work, and in many
a role in environmental health.
manufactured products. Some of these agents
Thousands of state and local agencies, includ-
are man-made, while some occur naturally, but
ing health, environment, and agriculture de-
they all have the potential to cause a wide range
partments, play critical roles in environmental
of adverse effects both acute and chronic, and
health, as frontline generators of knowledge
ranging from the minor to the severe. The up-
through surveillance and inspection and as
shot is that while the federal government must
regulators, acting both as partners with the fed-
take the lead in informing and promoting ac-
eral government and on their own. Also, as
tion, it cannot solve environmental health
noted, the involvement of citizens, businesses,
problems alone. These are community prob-
and community organizations is a precondition
lems that require community solutions.
to solving environmental health problems.
The obstacles to reducing environmental
However, it is the federal government that must
hazards are also compounded by a universe
provide the national leadership and resources
of competing values and interests. For ex-
necessary to create and disseminate necessary
ample, man-made chemicals and other po-
knowledge, and initiate the far-reaching action
tentially hazardous products deliver value to
required to protect all Americans from envi-
individuals and society, and efforts to clean
ronmental hazards. To meet its obligation, the
them up or eliminate them impose costs. In
federal government should take prompt action
this regard, health officials at all levels are
in the following areas:
challenged to assemble the knowledge
needed to target and justify prudent action
Background and Need for Action
Progress on environmental health requires
improving disease outcomes based on effec-
strong federal leadership and a sound strate-
tive prevention and control strategies.
gic approach based on the core principle of
I Strengthen federal leadership by designating
prevention and wise targeting of efforts and
a single official as the president’s environ-
resources to achieve maximum public health
mental health leader, with responsibility for
benefit. As currently structured and operat-
developing a comprehensive environmental
ing, the federal government cannot offer the
health strategy (including measures of
strong leadership and strategic direction nec-
progress), coordinating agencies to imple-
essary to effectively protect Americans from
ment this strategy, and reporting to Congress
environmental hazards. To do this, the fed-
and the public biennially on the state of envi-
eral government should:
ronmental health and progress achieved.
I Designate environmental health as a crucial
I Bring public health departments, urban
public health priority and commit to achiev-
planners, transportation experts, manu-
ing measurable progress in reducing health
facturers, developers, and the community
risk in social and physical environments and
101
into collaborative efforts to prevent and
action to improve environmental health.
solve environmental health problems, and
These would include assessments of the im-
provide adequate funding to do so.
pacts of decisions related to the built envi-
I
ronment. This process should include not
Ensure that environmental health consider-
only government agencies, but also busi-
ations are incorporated into national secu-
ness and community organizations.
rity and preparedness planning, including
plans to minimize the health impacts of ter-
I Consolidate America’s food safety agencies,
rorist attacks involving biological, chemical,
modernize food safety laws, and work closely
and radiological agents.
with state and local officials to create an inte-
I
grated, national food safety system, with a
Work through CDC to invest in building
clear public health mandate, to reduce the
state and local capacity for addressing en-
risk of foodborne illness. A primary objective
vironmental health problems, including a
must be to build the principle of prevention
well-trained workforce and up-to-date in-
into the nation’s food production, processing,
formation systems and technology.
and marketing system. Expand inspection ca-
I Create incentives and provide resources
pabilities and strengthen standards for im-
and technical assistance for states and
portation of food, as well as ensure safe
localities to perform community environ-
agricultural practices and food production in
mental health assessments as the basis for
countries from which U.S. food is imported.
Building and Disseminating Knowledge
The political will to act on environmental
I Strengthening the biomonitoring program
health problems depends in large part on hav-
of CDC’s Environmental Health laboratory
ing a clear understanding of their health and
by substantially increasing its funding; ex-
economic consequences. Effective action is
panding the role of state and local agencies,
then dependent on identifying the most im-
community groups, and the private sector
portant problems and most practical solu-
in the planning of data collection and
tions. Only the federal government has the
analysis; and integrating biomonitoring re-
capacity to lead the development of such
sults with surveillance results to produce
knowledge. Thus, to support the federal gov-
more useful information.
ernment’s strengthened leadership role on
I Improving scientific tools and elevating
environmental health and its capacity to help
the priority of investigating disease clusters
communities to solve problems, it should act
as potential indicators of significant envi-
to improve the development and dissemina-
ronmental health hazards.
tion of necessary information by:
I
I Fostering enhanced safety testing of po-
Fully funding and implementing CDC’s Na-
tentially toxic chemicals that are being re-
tional Environmental Public Health Tracking
leased into the environment by actively
Program and Tracking Network, as described
supporting voluntary public-private initia-
in CDC’s August 2006 National Network Im-
tives, such as the High Production Volume
plementation Plan, and developing bench-
Chemical Challenge, aggressively using
marks and performance measures to ensure
the legal tools available under the Toxic
that it is fulfilling its mission.
Substances Control Act, and by crafting in-
I Working to better integrate disease surveil-
novative new strategies, as illustrated by
lance systems and linking them to electronic
the European Union’s Registration, Eval-
health records so that more robust informa-
uation, Authori zation and Restriction of
tion is available on a timier basis to both bet-
Chemical substances (REACH) initiative.
ter detect and understand current and
emerging environmental health problems.
102
I Continuing to fully fund the National Chil-
I Making all data and analysis from govern-
dren’s Study, under the direction of the
ment tracking, surveillance, biomonitoring,
National Institute of Child Health and
research, and data programs more readily
Human Development (NICHHD), as a key
accessible in a useful form and on a timely
contributor to the environmental health
basis to all interested parties, including
knowledge base.
health agencies at all levels of government,
I
community organizations, researchers, and
Increasing investment in innovative envi-
the public at large.
ronmental research that addresses such is-
sues as the social determinants of
I Strengthening community right-to-know
environmental health including health
laws and aiding in their implementation to
disparities based on race, income, and
ensure that communities have the knowl-
other societal factors; the impact of envi-
edge they need to devise locally appropriate
ronment on mental health; and health im-
prevention and response strategies.
pacts of the built environment.
I Ensure a trained workforce, adequate re-
I Launching a major new effort to under-
sources, and clear guidelines, including a
stand and prepare to minimize the health
legal framework for action, to build ca-
impacts of climate change.
pacity to undertake remediation of envi-
ronmental hazards.
Building and Disseminating Knowledge
Leadership and knowledge are the basis for
I Report to Congress and the American peo-
action. Recognizing the range and diversity
ple biennially on progress and obstacles to
of environmental health problems, progress
achieving the goals.
can best be achieved through concerted ef-
I Make the prevention of adverse health im-
forts to address the most significant prob-
pacts an integral component of decisions re-
lems. To this end, in addition to continuing
lated to the built environment by
its regular environmental health activities,
requiring a federal health impact assessment
the federal government should:
in connection with the construction of new
I Identify the ten most significant environ-
federally-funded transportation and building
mental health hazards and opportunities
projects, and other major federal actions af-
to reduce risk, taking into account the
fecting the built environment, and provide
magnitude of the risk and the availability
incentives and technical assistance to states
of interventions to reduce them.
and localities to make similar assessments.
I Set specific goals for reducing risk within
I Work with communities to minimize dispar-
specified time periods and develop and im-
ities in environmental health that are based
plement action plans to achieve them
on differences in income, class, race, job ex-
through a combination of traditional regu-
posure, and other social determinants.
latory tools and incentive-based initiatives.
CONCLUSION
Progress in reducing the public health and eco-
requires a commitment by the federal govern-
nomic burden of environmental health hazards
ment to offer new leadership, build and dis-
is necessary and, with concerted and creative ef-
seminate necessary knowledge, and target
fort, possible. It’s time for our nation to move
action to reduce risk. By working with the com-
beyond the status quo and adopt a more strate-
munity, the federal government can help safe-
gic and targeted approach to responding to en-
guard the health of all Americans.
vironmental health challenges. Doing so
103
Agenda for Modernizing
Public Health
3
A P P E N D I X
PREVENTING INFECTIOUS DISEA SE --
MEETING THE CHALLENGE OF A GLOBAL
HEALTH AND ECONOMIC THREAT
Background and Need for Action
Infectious disease caused by bacteria, viruses,
sistent and evolving infectious disease threats all
and other pathogens continues to pose a mas-
over the world. For example, HIV/AIDS is
sive threat to public health and social and
thought to have originated in Africa, and new
economic stability both in the United States
strains of flu virus emerge regularly from Asia.
and around the world. Globally, one-third of
3. Poverty fosters infectious disease.
all deaths today are linked to infectious dis-
Americans who are poor, under-educated, and
ease. Malaria, measles, and diarrhea remain
under-employed, have poor nutrition, and live
leading killers while HIV/AIDS, the world’s
in areas plagued by blight, crime, and risky be-
fourth-leading cause of death, is ravaging
haviors are more vulnerable to the incidence
economies throughout Africa and Asia.
and spread of infectious diseases. Such popu-
In the U.S., killers like malaria, smallpox, polio,
lations are also less likely to have health insur-
and measles have largely been eliminated as a
ance and primary health care providers.
result of basic public health measures, such as
Against this backdrop, protecting the health of
improved sanitation, as well as the modern tools
Americans depends on our vigilance at home
of surveillance, immunization, and antibiotic
and abroad, and the capacity of federal, state,
treatment. Despite these successes, flu still
and local health agencies to anticipate, prevent,
claims 50,000 American lives every year, 1 mil-
and contain infectious disease outbreaks. Ab-
lion Americans are infected with the HIV virus,
sent this capacity, Americans remain vulnerable
and estimates suggest more than 19 million
to health disasters of staggering proportions.
Americans are newly infected with a sexually
Today, an influenza pandemic in the United
transmitted disease (STD) each year.
States on the scale experienced in 1918 could
However, the threat posed by infectious disease
afflict 90 million Americans and kill about two
goes well beyond the present number of cases
million Americans.168
and is being shaped by three unavoidable facts:
America’s economic security also hinges on
1. Infectious disease is inherently dynamic.
our sustained vigilance and our nation’s ca-
New bacterial and viral threats are constantly
pacity to rapidly respond to infectious disease
evolving and new forms of infection emerge
threats. It is estimated that a replay of the 1918
all the time. Thirty years ago, E. coli O157:H7
flu pandemic would now cost the U.S. econ-
and the HIV/AIDS virus were largely un-
omy $683 billion. Recent experiences have
heard of. Today, they are recognized as seri-
demonstrated that even much smaller infec-
ous public health problems.
tious disease outbreaks originating overseas can
have drastic economic consequences. For ex-
2. Globalization expands the risk of disease
ample, the 2003 outbreak of severe acute res-
exposure.
piratory syndrome (SARS) began in Asia,
With expanded international trade and eco-
spread to North America through travel of an
nomic integration, Americans increasingly en-
infected individual, and emerged most promi-
counter people, food, and other goods from
nently in Toronto. Three-hundred-seventy-five
other countries and are often exposed to per-
104
cases and 44 deaths occurred in Ontario, but
resistant TB (XDR-TB) are circulating globally
the economic cost to Toronto due to canceled
and could pose a renewed threat to the U.S. at
travel and conventions and other disrupted
a time when funding for TB control at the state
business activity was devastating, amounting to
level has been flat or has declined.
12,000 lost jobs, $1 billion in 2003 alone, and
Across the board, our nation’s capacity for pre-
two years of a depressed economy.170, 171, 172, 173
venting and containing infectious disease out-
Similarly, in a globalized food system, animal-
breaks is far less than it must be. It does not
borne infections with the potential to cross
have to be this way. With leadership from the
over to humans can have devastating economic
federal government, America can meet the
consequences, even if the number of human
new threat posed by infectious diseases by:
cases is relatively small. For example, avian flu
has severely damaged the poultry industries in
I Modernizing and integrating surveillance
Vietnam and Thailand and could easily do so
systems to rapidly detect, report, and ana-
here without the effective prevention and con-
lyze outbreaks.
trol measures necessary to maintain public
I Increasing the supply of critically impor-
confidence in food safety. The upheaval in the
tant vaccines and anti-viral drugs that are
U.S. beef industry in the wake of a 1990’s out-
chronically in short supply.
break of E. coli O157 and the damage to
spinach and lettuce growers due to recent out-
I Immunizing all children and adults.
breaks reminds us how high the stakes are.
I Advancing research and development of
We know from experience what it takes (sur-
new and improved diagnostics, drugs, and
veillance, immunization, treatment, and vari-
vaccines.
ous public health measures) to prevent and
I Expanding public access to the care nec-
contain the spread of many diseases. However,
essary to prevent the spread of HIV/AIDS
we too often forget that if America lets its guard
and other infections.
down even past successes can be reversed. Tu-
berculosis (TB) illustrates the point. Through
I Funding the state and local governmental
surveillance, screening, and new antibiotic
workforce that identifies these diseases,
treatments, the number of U.S. TB cases was
tracks their movement through communi-
steadily declining. For all practical purposes,
ties, provides treatment, contact tracing,
Americans assumed TB had been beaten. But,
and follow-up care, and works to prevent
we were wrong. Due to a dismantling of the in-
further infection.
frastructure for TB care, prevention, and con-
America cannot create the capacity necessary
trol, as well as globalization, drug resistance,
to prevent and contain infectious outbreaks
and co-infection with other infectious diseases,
absent a sustained commitment by policy-
new TB cases surged in the U.S. during the
makers. Leadership to maintain global vigi-
1980s and early 1990s, to a peak of nearly
lance and build the human and technical
25,000 in 1993. With renewed efforts, cases de-
capacity for prevention must come largely
clined to fewer than 14,000 in 2006.175 Now,
from the federal government.
even more virulent strains of extensively drug
Strengthening Surveillance and Outbreak Response
Preventing and containing infectious disease
border, our surveillance and investigation ca-
hinges on robust surveillance to detect out-
pacity must be global in its scope.
breaks and the capacity to respond to them.
In the U.S., infectious disease surveillance and
Both require effective reporting and active sur-
outbreak response is implemented primarily by
veillance mechanisms, laboratory capacity, and
state and local health agencies and health care
investigative resources. Without these, it is im-
providers, with the CDC playing a coordination
possible to contain outbreaks, discover root
and support role. Significantly, CDC also plays
causes, and devise preventive measures. Addi-
a key leadership role internationally, working
tionally, because infectious disease respects no
105
with the World Health Organization (WHO),
of surveillance capacity, including a well-
regional health bodies, and national govern-
trained and equipped workforce and ade-
ments to provide training, expertise, and direct
quate laboratory capacity.
support to surveillance activities and major out-
I Consistent with national security and legiti-
break investigations.
mate privacy concerns, promote transparent
To strengthen these efforts, the federal gov-
and rapid data sharing so that federal, state,
ernment should:
and local officials, and other stakeholders,
I
can take full advantage of disease surveil-
Develop and implement, in close collabo-
lance investments.
ration with state and local health agencies,
a national strategy to modernize domestic
I Bolster CDC’s international leadership role
surveillance systems and ensure the best
in improving global disease surveillance by
use of surveillance resources.
providing the resources necessary to sup-
I
port the development of key regional and
Promote the integration of current sur-
disease-specific surveillance systems.
veillance systems where possible, including
the sharing of data among systems, the use
I Develop a world-wide “network of net-
of Internet-based data entry, the introduc-
works” to foster more rapid information
tion of automated electronic laboratory re-
sharing and early detection of emerging
sults reporting, and encourage the use of
threats, making it a national priority.
electronic health records to simplify and
I Improve CDC’s contribution to interna-
enhance public health surveillance.
tional outbreak assistance by strengthen-
I Develop a financing plan and funding mech-
ing its operating procedures, human
anism to ensure that all states and localities
resources, and laboratory capacity.
can achieve a minimum acceptable standard
Pandemic Influenza Preparedness
The inevitability of a global influenza pan-
pandemic flu, and the development of inno-
demic makes preparedness fundamental to
vative new vaccines, with the ultimate goal of
our nation’s health and economic well-being.
developing a universal flu vaccine that can
Much effort is underway at government
prevent all strains of the virus.
health departments nationwide, but true pre-
I Accept shared responsibility for containing a
paredness requires sustained leadership by
pandemic globally by replacing the current
the federal government. Broadly, the federal
goals from the U.S Department of Health
government should update as needed, fully
and Human Services (HHS) (enough supply
fund, and promptly carry out the President’s
for the U.S. population within six months of
National Strategy for Pandemic Influenza Im-
the onset of an influenza pandemic) with a
plementation Plan.
far more ambitious goal for the production
More specifically, priority action should be
of a pandemic vaccine.
taken to:
I Streamline the Food and Drug Admini -
Strengthen International Collaboration
stration’s (FDA) licensing process for flu
I Strengthen international surveillance sys-
vaccine, increase seasonal flu vaccination
tems and working relationships to better
rates, and create added capacity for vaccine
identify and respond to flu outbreaks.
manufacturing and distribution.
Support Medical Interventions
I Implement at CDC a nationwide, real-time
I Develop a Pandemic Vaccine Research and
system to track the use, safety, and effec-
Development Master Plan that clearly assigns
tiveness of vaccines and foster the most ef-
leadership and accountability for ensuring an
ficient use of available vaccine supplies.
adequate supply of vaccines for seasonal and
106
I Increase the amount of federally funded an-
sites for triage and care, and health care
tiviral medication in the Strategic National
worker protections (such as vaccination)
Stockpile (SNS) to be able to treat 25 per-
and other incentives to stay on the job
cent of the U.S. population, and enhance
(such as adequate and affordable insur-
the SNS to include sufficient masks and res-
ance coverage).
pirators, gloves, syringes, and other critical
I Develop cost-effective, easy-to-use, point-
medical supplies, including chronic disease
of-care diagnostics to speed diagnosis and
medications that may be in short supply dur-
ensure appropriate care. This is also key
ing a pandemic. Consideration should also
to meaningful, real-time surveillance.
be given to making shelf-life extensions
available for certain pharmaceuticals owned
I Create an emergency health benefit to ensure
and managed by states as part of their emer-
that the public receives needed countermea-
gency stockpiles to reduce potential waste
sures and care in an influenza pandemic (or
and increase availability of critical materials.
similar public health emergency) regardless
I
of their insurance coverage.
Address problems related to medical surge
capacity, including identifying alternative
Foster Community Preparedness
I Engage schools, businesses, community-based
I Harmonize communications among layers
service organizations, and other stakeholders
of government and among sectors of soci-
in planning for implementation of non-med-
ety and conduct joint exercises to better
ical interventions to prevent and contain an in-
understand roles and responsibilities in a
fluenza pandemic, including school and
pandemic emergency.
business closings, isolation, and quarantine. A
I Confront “diminished standards of care,”
particular focus should be on vulnerable pop-
and resolve liability issues and other con-
ulations whose additional needs during a pan-
cerns related to health care that are antici-
demic should be anticipated.
pated during a pandemic and communicate
I Fund and implement a multi-lingual, cul-
about these problems with the public.
turally-appropriate risk communications
strategy well in advance of a pandemic.
Immunization
Immunization through vaccination of chil-
L Require insurers to cover all Advisory
dren and adults is effective as a means to pre-
Committee on Immunization Practices
vent some of the most serious infectious
(ACIP)-recommended vaccinations with-
diseases and should remain a public health
out deductible or co-pay;
priority. To ensure that the benefits of im-
L Expand public education and awareness
munization are fully realized, the federal gov-
to promote childhood vaccination;
ernment should:
I
L Make immunization a prerequisite con-
Fully fund all of CDC’s immunization pro-
dition for pre-school-age child care; and
grams and take other actions to improve
access and public support for vaccination,
L Enhance the development and use of elec-
with the goal of achieving a 100 percent
tronic immunization registries to monitor
vaccination rate among all Americans.
progress and target interventions.
I Take other specific steps to achieve 100
I Foster the development of innovative new
percent immunization, including:
vaccines by directly funding research and
L
by strengthening regulatory and economic
Expand access through the Vaccines for
incentives for private-sector investment in
Children Program;
vaccine research and development.
107
Antibiotic Resistance
Antibiotics are an essential weapon in the fight
I Strengthen strict FDA oversight of the use
against infectious disease. However, the natu-
of antibiotics in animal production to min-
ral evolution of resistance in bacteria to many
imize the development of resistance.
antibiotics undermines their effectiveness. For
I Develop incentives and standards to minimize
example, some strains of the foodborne
overuse of antibiotics in clinical settings, and
pathogens Salmonella and Campylobacter are
increase awareness about appropriate use
now resistant to multiple antibiotic drugs. To
among practitioners and the public.
address this growing problem, the federal gov-
ernment should:
I Provide regulatory and economic incentives
for the development of new antibiotics by
the pharmaceutical industry.
Preventing HIV/AIDS
Despite significant advances in prevention,
I Reinvigorate behaviorally-based HIV pre-
early diagnosis, and treatment, HIV/AIDS re-
vention programs that are targeted to in-
mains a serious public health problem in the
dividuals and communities at risk.
United States. More than one million people
I Fund broad access to proven preventive in-
are living with HIV, but roughly one quarter of
terventions in public health and health
them are unaware of their infection. Thus,
care settings, including use of condoms
continued vigilance and stepped up efforts to
and clean syringes.
prevent and treat the disease are critical pub-
lic health priorities. Specifically, the federal
I Support enhanced research into anti-HIV
government should act to:
vaccines and other preventive measures
I
such as microbicides.
Significantly enhance early diagnosis of
HIV positive individuals by:
I Ensure access to treatment for all unin-
L
sured persons with HIV in the U.S. and en-
Educating the public on the value of
sure treatment through appropriate
HIV testing;
expansions of HIV-specific and public
L Incorporating HIV testing as a routine part
insurance programs.
of care in traditional medical settings; and
I Support continuation and expansion of
L Implementing new models for diagnosing
U.S. support for global programs to pre-
HIV infections outside medical settings, in-
vent and treat HIV.
cluding the use of rapid testing methods,
to make testing more accessible.
CONCLUSION
Reducing, and in some cases eradicating, in-
must build on what we have learned about
fectious diseases is one of the American pub-
surveillance, immunization, and treatment.
lic health system’s greatest triumphs. It also
This is a challenge we can meet if our leaders
remains one of our nation’s most important
renew America’s commitment to public
challenges as our past success has too often
health, mount sustained efforts, and do what
been allowed to foster complacency. We
we know works to prevent infectious disease.
108
Agenda for Modernizing
Public Health
DISASTER PREPAREDNESS AND EMERGENCY
4
A P P E N D I X
RESPONSE -- BUILDING THE CAPACITY OF
THE PUBLIC HEALTH SYSTEM
Background and Need for Action
The September 11 attacks, Hurricane Kat-
level of preparedness on a consistent, sus-
rina, the potential of pandemic flu, and the
tained basis nationwide.
ongoing threat of bioterrorism make clear
Today, some 3,000 state and local agencies
the need to be prepared for the public
share the responsibility of providing the vital
health consequences of extraordinary
public health services that are fundamental
events. Failing to prepare can transform a
to effective emergency response. These
crisis into a health disaster and lead to
agencies are so chronically under funded
human suffering and economic losses that
that they often lack the human resources,
could have been avoided.
laboratory capacity, and other tools neces-
The federal government recognizes this fact,
sary to perform their routine work. Now
as evidenced by the passage of the Public
they are being asked to prepare for the ex-
Health Security and Bioterrorism Act of 2002
traordinary demands they may face in a dis-
and the Pandemic and All-Hazards Pre-
aster or other emergency.
paredness Act of 2006 (All-Hazards Act). In
Since 2002, Congress has appropriated about
the All-Hazards Act, Congress directed the
$1 billion annually for public health pre-
Secretary of Health and Human Services
paredness purposes, although funding for
(HHS) to, among other things, develop a Na-
state and local preparedness activities has de-
tional Health Security Strategy to integrate
clined significantly over the past several years.
public and private medical capabilities with
These resources and the efforts of many state
other first responder systems and bolster the
and local officials made a positive difference
emergency response capacity of federal,
in preparedness planning, training, and ex-
state, and local health agencies.
ercising; building necessary stockpiles of vac-
The All-Hazards Act affirms the fact that, to
cines and other medical supplies; building
be truly effective, public health preparedness
laboratory and surveillance capacity; vacci-
and emergency response planning must be
nating at-risk populations; and building surge
community undertakings. While the federal
capacity in hospitals. The pace of progress
government can -- and must -- provide critical
varies across the country, however, and, across
leadership and financial support, America’s
the board, much more needs to be done.
success in preparing for, and responding to,
Strong federal leadership and sustained and
emergencies hinges on public-private collab-
expanded financing will be required.
oration in every city and town and will ulti-
The All-Hazards Act offers a useful frame-
mately succeed or fail locally. While
work and the tools needed for this effort, but
considerable progress has been made, much
its promise cannot be fully realized until the
remains to be done to achieve an acceptable
federal government fully funds and imple-
109
ments it. In addition, federal policymakers
public. Some of these issues are addressed
should address a series of other priorities:
in the All-Hazards Act, but our leaders will
leadership and accountability; surge capacity
need to build on it if America is to have the
and the workforce; technology and equip-
robust preparedness and emergency re-
ment; and broader partnerships with the
sponse capacity our nation needs.
Leadership and Accountability
In a public health system as decentralized as
ation (such as through the Emergency Man-
ours, national leadership is essential to ensure
agement Assistance Compact) to prepare
that disaster and emergency threats are prop-
for and respond to health emergencies.
erly assessed and that standards for prepared-
I Establish measurable, optimally achievable
ness are set and maintained. At the same
preparedness performance standards that
time, state and local governmental leadership,
all federal agencies and federally-funded
supported by sufficient federal funding, is
states and localities should be held ac-
needed to create and sustain local response
countable for achieving.
capacity. The system as a whole must be trans-
parent and fully accountable for making the
I Require regular testing and assessment on
best use of limited resources. To achieve these
a community-wide basis to measure
goals, the federal government should:
progress in satisfying the performance
I
standards.
Designate a single official in HHS to be re-
sponsible, accountable, and fully empow-
I Ensure that the results of such testing and
ered to plan and coordinate implementation
assessments are easily accessible to policy-
of the National Health Security Strategy
makers and the public in a timely manner.
called for by the All-Hazards Act; this official
I Make federal funding of programs contin-
should either perform or oversee all the pre-
gent on satisfactory progress toward pre-
paredness-related activities of the new Assis-
paredness standards and limit carry-over
tant Secretary for Prepared
ness and
funding in states that have failed to meet
Response, the Assistant Secretary for Health,
this requirement.
and all other components of HHS. Further,
he or she must ensure the needed coordi-
I Partner with states to design a stable, long-
nation and integration across all the agen-
term funding mechanism for disaster pre-
cies that have a role to play.
paredness and emergency response that
I
incorporates both federal funds and state
Foster community-based planning, public-
matching funds.
private collaboration, and regional cooper-
110
Surge Capacity and the Workforce
Emergencies place a tremendous strain on
costs of training, administering, and or-
an already over-stretched public health work-
ganizing the volunteer workforce.
force, including first responders, lab person-
I Increase funding and accelerate implemen-
nel, doctors, and nurses, and on the capacity
tation of the Health Resources and Services
of hospitals. It is thus essential to pay special
Administration’s (HRSA) Emergency Sys-
attention to the surge capacity of the public
tem for Advance Registration of Volun teer
health workforce and the nation’s hospitals
Health Professionals.
and clinics. To this end, the federal govern-
ment should:
I Improve hospital surge capacity by fully
I
funding and implementing the authority
Strengthen the federal, state, and local
in the All-Hazards Act to establish partner-
regular public health workforce by fully
ships among medical facilities, including
funding and implementing the workforce
hospitals, clinics, and nursing homes, and
enhancement provisions of the All-Haz-
state and local governments aimed at im-
ards Act and strengthening incentives for
proving overall preparedness and surge ca-
trained personnel to commit themselves to
pacity for public health emergencies.
public health and emergency response
roles.
I Establish standards in public health
I
training and curricula, and incorporate
Provide for a supplemental, volunteer
into accreditation for schools of public
workforce trained to assist in large-scale
health and other settings where the pub-
emergencies by enhancing recruitment,
lic health workforce is educated, so that fu-
training, and retention of volunteer med-
ture public health practitioners have the
ical personnel in the National Disaster
skills and knowledge they need to protect
Medical System and the Medical Reserve
the public’s health in both emergency and
Corps. Ensure funding to support the
day-to-day situations.
Technology and Equipment
State-of-the-art surveillance techniques and
ing improved test methods and adequate
ready access to needed vaccines and treat-
supplies of reagents.
ment drugs are fundamental to protecting
I Expand research and development of vac-
the public from acts of bioterrorism, natural
cines, diagnostics, and other countermea-
disasters, and emerging disease threats.
sures by fully funding and implementing
Thus, the federal government should:
the mandates of the Biomedical Advanced
I Continue working toward modernized sur-
Research and Development Authority
veillance systems that are interoperable
(BARDA).
among agencies at all levels of government.
I Bolster the Strategic National Stockpile of
I Continue funding for maintenance and
medicines, equipment, and lab supplies
resupply of equipment and drugs now in
needed to respond to emergencies
use for surveillance and treatment.
through research, development, produc-
I
tion and acquisition of needed items.
Improve laboratory capacity to test for
chemical and biological hazards, includ-
111
Community Involvement
Generating public awareness and understand-
I Modernize risk communication to improve
ing of potential emergencies and the role of
the dialogue with groups and individual
federal, state, and local governmental public
members of the public, not only to provide
health authorities in responding to them is es-
factual information, but to foster coopera-
sential to the success of even the best-funded
tive involvement in emergency response.
initiatives. Business and community groups are
I Reach out to and better address the spe-
also important players because of their strong
cial needs of vulnerable populations, in-
links as service providers or sources of infor-
cluding children, the elderly, and those
mation for millions of people. The federal gov-
with chronic disabling diseases.
ernment, together with state and local
agencies, should view the public as a partner in
I Establish a temporary “state of emergency”
responding to emergencies and bolster that
health benefit to encourage the uninsured
partnership by taking actions to:
or underinsured to obtain proper diagnosis
I
and treatment in public health emergencies
Actively reach out to business, community
without regard to insurance coverage.
groups, and other stakeholders, including
the media, to involve them in shaping pre-
I Establish stable and secure sources of
paredness and emergency response plans.
funding for state and local governmental
I
public health departments to facilitate the
Work with state and local governments to
development and maintenance of com-
ensure they have the necessary legal au-
munity involvement.
thority and procedures to respond rapidly
to public health emergencies.
CONCLUSION
Human nature makes it difficult to maintain
plementation of preparedness initiatives by
a steady focus on preparing for future emer-
governmental and non-governmental health
gencies as memory of the last one fades. The
agencies in federal, state, and local jurisdic-
intensity of recent experiences has brought
tions. The pay-off will come in both reduc-
a strong response from Congress, but sus-
ing the toll of future disasters and
taining the priority and commitment that
emergencies and strengthening the overall
preparedness now enjoys will depend on far-
capacity of the public health system to meet
sighted political leadership and excellent im-
the nation’s ongoing health needs.
112
Endnotes
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3 Based on 2005 spending levels. The analysis ex-
10 U.S. House. Committee on Energy and Com-
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Health Law, as Amended Through December 31,
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89 Braveman P and Egerter S. Overcoming Obstacles
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78 Behan D.F. et al. Economic Effects of Environ-
90 U.S. Centers for Disease Control and Prevention.
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92 Johnson, K., et. al. “Recommendations to
128 Recreated from: http://www.ihs.gov/PublicInfo/
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93 Ibid.
129 Budget In Brief, Department of Health and
94 Trust for America’s Health. Healthy Women, Healthy
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130 Recreated from: http://www1.od.nih.gov/oma/
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131 Recreated from: http://samhsa.gov/About/
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orgcharts/org_all.aspx
95 http://www.bls.gov/data/inflation_calculator.htm
132 http://www.hhs.gov/ophs/
96 http://officeofbudget.od.nih.gov/UI/2008/
133 Recreated from: http://www.omhrc.gov/
BRDPI%20Table%20of%20Annual%20Formu-
templates/content.aspx?ID=868&lvl=1&lvlID=7
las_01_04_2008.pdf
134 http://www.omhrc.gov/templates/
97 Recreated from: http://www.hhs.gov/about/
browse.aspx?lvl=1&lvlID=7
orgchart.html
135 Recreated from: http://hhs.gov/aspr/about
98 Recreated from: http://www.ahrq.gov/about/
us/organization/index.html
orgchart.pdf
136 http://hhs.gov/aspr/
99 Recreated from: http://cdc.gov/maso/pdf/cdc.pdf
137 Ibid.
100 http://www.cdc.gov/ncbddd/
138 Ibid.
101 http://www.cdc.gov/nccdphp/
139 Ibid.
102 http://www.cdc.gov/nccdphp/publications/
140 Ibid.
aag/blockgrant.htm
141 As used here, the term “health system” refers
103 Ibid.
broadly to health care providers, governmental
104 http://www.cdc.gov/genomics/
public health agencies, and the many other insti-
105 http://cdc.gov/about/organization/ccid.htm
tutions and activities of society that affect our
106 Ibid.
health, including business, education, trans-
portation, and community planning. “Health
107 Ibid.
care providers” include doctors, hospitals, public
108 Ibid.
clinics, insurers, and other organizations in-
109 http://cdc.gov/about/organization/ccehip.htm
volved in providing and paying for individual
medical treatment and other individual health
110 http://www.atsdr.cdc.gov/
care services, including preventive health care
111 http://cdc.gov/about/organization/ccehip.htm
services. “Public health agencies” include fed-
112 http://cdc.gov/about/organization/cchis.htm
eral, state, and local agencies, such as health de-
113 Ibid.
partments and laboratories, that focus on the
health of the population and conduct health
114 Ibid.
surveillance,investigate and manage illness out-
115 http://cdc.gov/about/organization/cogh.htm
breaks and other health problems, and generate
116 http://cdc.gov/about/organization/cotper.htm
knowledgeand manage programs to prevent ill-
ness withinthe population.
117 Ibid.
142 U.S. Centers for Disease Control and Preven-
118 Recreated from: http://www.fda.gov/oc/
tion. “Fact Sheet, Cigarette Smoking Related
orgcharts/FDA051508.pdf
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119 http://www.fda.gov/opacom/factsheets/
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justthefacts/4cber.html
<http://www.cdc.gov/tobacco/data_
120 http://www.fda.gov/opacom/factsheets/
statistics/Factsheets/cig_smoking_mort.htm>
justthefacts/5cdrh.html
(Accessed May 2007).
121 http://www.fda.gov/opacom/factsheets/
143 U.S. Centers for Disease Control and Preven-
justthefacts/3cder.html
tion. “Progress in Improving State and Local
122 http://www.fda.gov/opacom/factsheets/
Disease Surveillance – United States, 2000
justthefacts/2cfsan.html
2005,” Morbidity and Mortality Weekly Report
54:33 (August 2005).
123 http://www.fda.gov/opacom/factsheets/
justthefacts/6cvm.html
144 Catlin, A.., et al. “National Health Spending in
2005: The Slowdown Continues,” Health Affairs
124 http://www.fda.gov/nctr/index.html
26, no. 1 (2007).
125 Recreated from: http://www.hrsa.gov/about/
145 U.S. Centers for Disease Control and Prevention.
orgchart.htm
The Burden of Chronic Diseases and Their Risk Factors:
126 http://www.hrsa.gov
National and State Perspectives 2004. Atlanta: U.S. De-
127 June 2007 Senate Labor, HHS and Related
partment of Health and Human Services; 2004.
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<http://0www.cdc.gov.mill1.sjlibrary.org:80/nccd-
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117
146 Hales, S. “More effective care: disease
158 American Cancer Society. Cancer Facts and
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8, 2007).
May 8, 2007).
159 Rosamond, W., et al. “Heart Disease and Stroke
147 Rand Corporation. “Future Health and Medical
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148 Silow-Carroll, S. and T. Alteras. “Stretching State
160 American Diabetes Association. “Total Preva-
Health Care Dollars During Difficult Economic
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<http://diabetes.org/diabetes-statistics/preva-
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161 U.S. Department of Health and Human
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149 American Diabetes Association. “Statement of
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162 Ibid.
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163 Ibid.
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164 Nelson, N. “The Majority of Cancers are
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150 American Cancer Society. “How Many Women
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165 U.S. Department of Health and Human Serv-
151 Barkley, P.M. “The Economic Impact of Tobacco
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<http://www.cdc.gov/nceh/ehs/EPHLI/Re-
152 U.S. Centers for Disease Control and Preven-
sources/Healthy_People_2010_Progress_Re-
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166 U.S. Environmental Protection Agency. “High-
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<http://www.cdc.gov/tobacco/data_statis-
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healthchildren/highlights/index.htm>
153 Indiana State Government. “INShape Indiana.”
(accessed May 8, 2007).
<http://www.in.gov/inshape/> (accessed Octo-
167 Other federal regulatory agencies with environ-
ber 1, 2008).
mental health responsibilities include the Occu-
154 Ibid.
pational Safety and Health Administration, the
155 Hales, S. “More effective care: disease manage-
Food and Drug Administration, and multiple
ment concepts and goals,” EAP Association Ex-
components of the Department of Agriculture.
change, September 1, 2002.
A host of federal agencies play important roles in
<http://www.accessmylibrary.com/coms2/sum-
developing the knowledge needed to identify en-
mary_0286-9147428_ITM> (May 8, 2007).
vironmental hazards and assess their risks, in-
156 Rand Corporation. “Future Health and Med-
cluding CDC’s National Center for
ical Care Spending of the Elderly,” Research
Environmental Health (NCEH), Coordinating
Brief, Rand Corporation, 2005.
Center for Infectious Diseases (CCID), and Na-
<http://www.rand.org/pubs/research_briefs/R
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B9146-1/index1.html> (accessed May 8, 2007).
Health (NIOSH); the Agency for Toxic Sub-
stances and Disease Registry (ASTDR); the Na-
157 Silow-Carroll, S. and T. Alteras. “Stretching State
tional Institute of Environmental Health
Health Care Dollars During Difficult Economic
Sciences (NIEHS); and FDA’s National Center
Times: Overview,” The Commonwealth Fund, Oc-
for Toxicological Research (NCTR).
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publications/publications_show.htm?doc_id=243
168 U.S. Department of Health and Human Services,
623> (accessed May 8, 2007).
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partment of Health and Human Services, Novem-
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118
169 Trust for America’s Health, Pandemic Flu and the
173 Ibid.
Potential for U.S. Economic Recession, Washington,
174 U.S. Centers for Disease Control and Preven-
DC: Trust for America’s Health, March 2007.
tion. “Trends in Tuberculosis Incidence -
<http://www.healthyamericans.org/flureces-
United States, 2006,” Morbidity and Mortality
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Weekly Review 56: 11 (March 2007).
170 World Health Organization, “Epidemic and Pan-
<http://www.cdc.gov/mmwr/pre-
demic Alert Response: Summary of probably
viewmmwrhtml/mm5611a2.htm> (accessed
SARS cases with onset of illness from 1 Novem-
May 11, 2007).
ber 2002 to 31 July 2003.” Based on data as of 31
175 Ibid.
December 200 <http://www.who.int/cs/
176 Trust for America’s Health, Ready or Not? Pro-
sars/country/table2004_04_21/en/index.html>
tecting the Public’s Health from Diseases, Disasters,
(accessed May 11, 2007).
and Bioterrorism, Washington, DC: Trust for
171 Cooper, S., The Avian Flu Crisis: An Economic
America’s Health, December 2006.
Update, BMO Nesbitt Burns, March 2006.
<http://healthyamericans.org/reports/
172 World Health Organization, “Epidemic and Pan-
bioterror06/> (accessed May 11, 2007.)
demic Alert Response: Summary of probably
SARS cases with onset of illness from 1 Novem-
ber 2002 to 31 July 2003.” Based on data as of 31
December 2003 <http://www.who.int/
sr/sars/country/table2004_04_21/en/
index.html> (accessed May 11, 2007).
119
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