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Currently Skimming:

2 Reforming Public Health and Its Financing
Pages 45-74

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From page 45...
... The nation is not buying what is needed to produce the health outcomes that it seeks.3 In this chapter, the committee examines the financing misalignment in more detail, focusing on the public health department capabilities that are needed for all or most programs (for example, in communication, information systems, and policy 1Recommendation 1: The secretary of health and human services should adopt an interim explicit life expectancy target, establish data systems for a permanent health-adjusted life expectancy target, and establish a specific per capita health expenditure target to be achieved by 2030. Reaching these targets should engage all health system stakeholders in actions intended to achieve parity with averages among comparable nations on healthy life expectancy and per capita health expenditures.
From page 46...
... . The core mission and unique competence of the governmental public health agencies (public health departments)
From page 47...
... is aligned with population health needs. A survey of 17 of the largest metropolitan health departments in the United States conducted by Georgeson and colleagues (2005)
From page 48...
... THE IMPACT OF PUBLIC HEALTH ACTION The history of public health attests to its ability to achieve major improvements in population health. Historically, action on the leading causes of death and disability in the population has involved public health departments at all levels working in collaboration with researchers, communities, clinical care providers, and other partners to collect data, plan and implement programs, advocate for policy change, enforce laws, and ensure the delivery of services, such as immunizations and occupational safety.
From page 49...
... The committee was unable to find a comprehensive and detailed assessment of public health funding and the effects of fluctuations in it over the last few decades. But it did find evidence of the historical instability of public health funding and of the absence of a long-term commitment from Congress and state policymakers to sustain it.
From page 50...
... . Researchers have assessed the likely impact of funding cuts in specific areas of public health, such as vectorborne disease control and other infectious and chronic disease control activities, and concluded that inadequate funding leaves public health departments ill equipped to prevent and control disease (LaBeaud and Aksoy, 2010; Meyer and Weiselberg, 2009)
From page 51...
... . The organization of governmental public health has developed in ways that reflect funder dictates, the flows of money, tightly compartmentalized programmatic categories, and the skill of public health leaders in "braiding" together disparate funding streams and finding new funding sources more closely than the needs of localities, including priorities based on communities' disease burdens, interests, and capabilities.
From page 52...
... The federal governmentigure 2-1 F disburses funds to state health departments through multiple agencies (such as CDC and the Health Resources and Services Administration) Bitmapped and avenues, including block grants, programmatic grants, and competitive grants, for instance, Title V/Maternal Child Health, Title X/Family Planning, Public Health Emergency Preparedness/Assistant Secretary for Preparedness and Response funds, and the Preventive Health and Health Services Block Grant.
From page 53...
... Some local health departments also receive funds from other state or local agencies, for example, in states where Medicaid, substance abuse services, or environmental health services are separate from state health departments. Local health departments receive a substantial amount of their funding from city or county (or multicounty)
From page 54...
... . Categorical funding may also limit the range of practice of public health departments; because categorical streams generally are not dedicated to the broader determinants of health, public health departments may not have funding to consider activities in this part of their purview (for example, gathering, analyzing, and disseminating information on transportation, housing, zoning, and other community factors that are known to be linked with health outcomes)
From page 55...
... The National Association of County and City Health Officials (NACCHO) 2010 Profile of Local Health Departments estimates that the largest proportion of local public health department revenue (26 percent)
From page 56...
... . One example of suboptimal coordination occurs when state and local health departments receive federal funding for overlapping purposes or without adequate coordination (for example, the CDC Racial and Ethnic Approaches to Community Health program and the Community Transformation Grants program)
From page 57...
... DEFINING THE MINIMUM PACKAGE OF PUBLIC HEALTH SERVICES The Three Core Public Health Functions (of assessment, assurance, and policy development) and the 10 Essential Public Health Services9 provide a well-known framework for categorizing activities of state and local health departments.
From page 58...
... aOthers have described something roughly equivalent. See for example NACCHO's 2011 profile of local health departments which provides the following list of "core public health activities that were to constitute the minimum services expected from Figure 2-2 the local units: vital statistics, sanitation, communicable disease control, maternal and child health, health education, and laboratory services" (NACCHO, 2011a, p.
From page 59...
... However, current funding methods typically do not support the financing of what the committee considers foundational capabilities that are needed to support effective and efficient programs. Agencies therefore often rely on categorical funding to build such capabilities, which accordingly become program-specific -- such as communication for the purpose of preventing and reducing smoking -- and are generally inconsistent among programs or public health departments.
From page 60...
... In the rare cases in which funding is provided, it is limited to specific programs, for example, funding to develop communication capacity for tobacco control or surveillance for infectious diseases. As a result, public health departments have developed foundational capabilities unevenly, inefficiently, and incompletely.
From page 61...
... Without specific enumeration, any given program activity may appear "optional" and thus easier to cut when budgets are tight. A definition of basic programs would clarify what every health department needs to make available (for example, tobacco control programs could never be considered optional)
From page 62...
... To provide support for the minimum package, the federal departments and agencies that fund state and local public health departments would take the steps described in Recommendation 2 earlier. HHS; USDA, which supports local Women, Infants, and Children Supplemental Nutrition Programs; the Environmental Protection Agency, which supports state air quality and other programs; and others could make administrative rule changes and procedural changes in the existing funding streams (such as contracts, grants, and cooperative agreements)
From page 63...
... . Public health departments could also expand their roles as conveners of relevant constituencies to promote action on high-priority health issues and as the definitive source of population health expertise in intersectoral collaborations (IOM, 2011b)
From page 64...
... As outlined in the committee's report on measurement, transforming governmental public health departments requires greater and more granular data and information that can be used to implement the functions of assessment, policy development, and assurance. Key knowledge and analytic capabilities specific to public health professional training and background
From page 65...
... . THE RELATIONSHIP BETWEEN PUBLIC HEALTH AND CLINICAL MEDICINE: A NEW PARTNERSHIP The committee's charge in this report is to "make recommendations for funding state and local public health systems that support the needs of the public after health care reform." A central issue that the committee grappled with was its vision of the relationship between public health and the medical care delivery system in the context of health care reform (the implementation of the Affordable Care Act [ACA]
From page 66...
... care, in the form of local performance reports on the appropriateness, quality, safety, and efficiency of clinical care services delivered in their community.13 Some health departments that serve small populations may never achieve local capacity, knowledge, and skills for collaborating with clinical care counterparts; in some states or territories, it may require a more centralized function, but governmental public health nevertheless needs to provide information to the medical care system and to the public it serves on the effectiveness and efficiency of its operation. Current examples of this sort of interaction or integration between the public health and clinical care systems include • R eports of outlier rates of hospitalization for selected diseases.
From page 67...
... Some issues may make it more appropriate for public health departments to provide specific kinds of clinical services directly, for example, specialized programs that have a population health component, such as programs related to control of tuberculosis or sexually transmitted diseases, 14"Because public health departments do not have legally enforceable duties to individuals, they also have greater latitude to commingle funds and engage in cross-subsidization practices to keep their activities afloat. Thus, for example, a public health agency may pool revenues from grants, contracts, patient fees, and third party payments (most typically Medicaid)
From page 68...
... The prominence of the focus on clinical care delivery was viewed by the committee as detracting from the ability of public health to take on other activities that are important for its mission and that others are less able to accomplish. However, the important and continued need for safety net services in many communities will require coordination between public health departments and public and private clinical care providers.15 Recommendation 4: The committee recommends that as clinical care provision in a community no longer requires financing by pub lic health departments, public health departments should work with other public and private providers to develop adequate alternative capacity16 in a community's clinical care delivery system.
From page 69...
... . Arrangements that would leverage economies of scale for public health departments face multiple barriers, but there are various ways to help small departments to work with others to achieve greater capacity, such as consolidation and sharing resources (Kaufman, 2011; Libbey and Miyahara, 2011)
From page 70...
... Preventive Health and Health Services Block Grant. A Critical Public Health Resource at a Glance 2011.
From page 71...
... 1996. Local health departments effectiveness in addressing the core functions of public health: Essential ingredients.
From page 72...
... 2012. Operational Definition of a Functional Local Health Department.
From page 73...
... 1994. Local health department effectiveness in addressing the core functions of public health.


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