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 INTRODUCTION 1 SECTION Blueprint for a Healthier America: 1 SECTION MODERNIZING THE FEDERAL PUBLIC HEALTH SYSTEM TO FOCUS ON PREVENTION AND PREPAREDNESS A merica 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 A. Our Vision for a Healthier America. Contain Costs and Improve Health. More than 140 leading health organizations Recommendations for improving prevention have signed on to a vision statement outlin- services offered by Medicare and ensuring ing the need to make disease and injury pre- Americans are healthier when they reach vention the centerpiece of our national Medicare age. 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 York Academy of Medicine to convene ex- Section 3: Trust for America’s 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 public health and examines how government B. F as in Fat: How Obesity Policies Are funding must be a shared responsibility at the Failing in America. Recommendations for federal, state, and local levels. a National Strategy to Combat Obesity B. Federal Health Agencies: C. Ready or Not? Protecting the Public’s Restructuring for a Healthier America. Health from Diseases, Disasters, and Recommendations for creating the optimal Bioterrorism. Recommendations for fixing structure necessary to improve public the gaps in public health emergency health programs and services across federal preparedness. 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- force experts for ways to recruit and retain Section 4: Overview of Federal 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 T he 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 Katie Adamson, Director of Health and Territorial Health Officials Partnerships and Policy, YMCA of the USA Ramon Bonzon, MPH, Program Associate, Denise Adams-Simms, MPH, Executive National Association of County and City Director, California Black Health Network Health Officials Nancy Adler, PhD, Director, Center for Jo Ivey Boufford, MD, President, The New Health and Community, University of York Academy of Medicine California, San Francisco Courtney Brein, Policy Associate, The New Gregg Albright, Deputy Director, Planning York Academy of Medicine 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 Bernie Arons, MD, Executive and City Health Officials 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 Ed Baker, MD, MPH, Director, North Officials 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 Polly Bednash, PhD, RN, FANN, Executive County and City Health Officials Director, American Association of Colleges Maureen Budetti, MA, Director of Student of Nursing Aid Policy, National Association of Suzanne Begeny, MS, RN, Director of Independent Colleges and Universities Government Affairs, American Association Charlene Burgeson, Executive Director, of Colleges of Nursing National Association for Sport as Physical Georges Benjamin, MD, FACP, FACEP(E), Education Executive Director, American Public Health Terry Buss, PhD, Director, International Association Studies, National Academy of Public Bob Berenson, MD, Senior Fellow, Urban Administration Institute Jeremy Cantor, MPH, Program Manager, Ron Bialek, MPP, President, Public Health Prevention Institute Foundation David Chavis, PhD, Principal Associate and Michael Bird, PhD, MSW, MPH, Private CEO, Association for the Study and Consultant Development of Community 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, Sylvia Pirani, MPH, Director, Office of American Psychological Association 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 Gillian Silver, MPH, Manager, Research Homeland Security Council 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 A merica 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 workforce well helps American businesses I 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 INFRASTRUCTURE SECTION R E C O M M E N D AT I O N S 2 SECTION 2 Infrastructure Recommendations A. FUNDING PUBLIC HEALTH FOR A HEALTHIER AMERICA 2 SECTION 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 health experts about the best ways to deter- I 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 Development (OECD) countries, which ranges I 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 NHEA), it would equal $59 billion, an increased I 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 [percent] of the time throughout the state.”7 I 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 Creating demonstration or pilot programs I 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 per capita basis. I Estimates excluded investment by non- government agencies. The estimates did not include tribal contributions. Since the State Investment 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 an effective response in a public health I 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 Facilitate the formulation of public I 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 prevention, TFAH assembled the following I 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 cap on the number of active members I 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), the Centers for Disease Control and Pre- L 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. Because of the cap on Corps members, I 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 are paid by the agencies where they work; I 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 funds. Another approach could be to tie I 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 such functions, health departments should I 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- ficiency and compliance with federal criteria I 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 the opportunity for a mid-course correction I 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. Funding and Accountability I 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 plans for improving performance in areas L 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 period, CDC, in consultation with states, L 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 positive incentive and reward for achieving I CDC should establish a coordination accreditation. mechanism for ongoing consultation and collaboration with the PHAB. L Creating a two-tiered special infrastructure grant fund that would support filling gaps I 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 CDC’s National Center for Chronic Disease L 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 The Public Health Service Act, which in- I 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 because of the cap mentioned above. L 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 emergency public health workforce, but the I 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 chronic diseases; I 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 group; and I 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 TRUST FOR AMERICA’S H E A L T H I N I T I AT 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 Recommendations 3 SECTION A. PREVENTION FOR A HEALTHIER AMERICA: INVESTMENTS IN DISEASE PREVENTION YIELD SIGNIFICANT SAVINGS, STRONGER COMMUNITIES -- RECOMMENDATION FOR A NATIONAL HEALTH AND PREVENTION STRATEGY T he 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- try, education, civic and faith-based commu- I 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 percent rating developing vaccines for pandemics as very im- L 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 support from a new Under Secretary of I 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 very concerned. I 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 immediately into question. Nearly every- I 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 every 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- ception health and health care, including L 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 Development of the National Institutes L 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 and Budgets 4 SECTION T his 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- gram is only able to fund 22 states and one I 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- cently the agency submitted a professional I 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- tion is factored in, this represents a cut of I 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 CHART 97 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, Center for Health Resources Director, Office Support Medicare & and Services of Civil Rights Center 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 CHART 98 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 of proposed policy changes. I 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 CHART 99 Office of the Office of CDC Strategy and Chief Science 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 Zoonotic, Vector- National Center for Injury for Health Chronic Disease Borne and Enteric Prevention and Control 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 Diseases 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- tional Center for Environmental Health L 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 disease symptoms caused by expo- L 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 CHART 118 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 Office of Medicine Radiological Science and Executive Pediatric Health Health Operations Office of Coordination Therapeutic Policy and Office of Planning 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, which are regulated by the Department of Agriculture. I 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 spongiform encephalopathy (BSE), commonly referred to I 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 CHART 125 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 Communications Center for Office of Planning Quality and Evaluation Office of Management Office of Minority Health 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 PROGRAMS 126, 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 CHART 128 Office of Tribal Self- Director Office of Governance Urban 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 ORGANIZATION AND MAJOR PROGRAMS 1 2 9 Services are delivered in the following ways: viding medical care, which includes sub- stance abuse prevention and treatment, to I 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 equipment. I 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 CHART 130 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 Development Disorders Kidney Diseases Bioengineering Research 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 ORGANIZATION AND MAJOR PROGRAMS 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 CHART 131 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 CENTERS AND MAJOR PROGRAMS 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 Commissioned 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 Overseeing the Center for Cultural and I 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 Supervising grant initiatives that facili- L Providing staff for the Advisory Com- tate community linkages and strategies. mittee on Minority Health; 84 OFFICE OF MINORITY HEALTH ORGANIZATIONAL CHART 133 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 CHART 135 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 SECTION 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 Strengthen collaboration among public nancial and technical assistance for state and 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- ing comprehensive state tobacco control I 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- tive countermeasures, such as vaccines, and I 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 ACTING TO PREVENT CHRONIC DISEASE – A 1 APPENDIX 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 objective of any federal reform of the I 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 of the wellness and prevention programs I 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 Health Insurance Program. I 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. L Communicating physical activity guide- I 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 required prior to the construction of new I 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, and action plans to reduce them. I 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 improving health outcomes, through CDC’s I 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 2 APPENDIX Agenda for Modernizing Public Health 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 the distribution and growth of chemical I 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 health problems impose significant economic I 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- ronment. This process should include not I 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- grated, national food safety system, with a I 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 Fostering enhanced safety testing of po- I 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, Authorization 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, community organizations, researchers, and I 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 3 APPENDIX Agenda for Modernizing Public Health 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, can take full advantage of disease surveil- I 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- port the development of key regional and I 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 of their insurance coverage. I 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: L Make immunization a prerequisite con- I 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 by strengthening regulatory and economic L 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 such as microbicides. I Significantly enhance early diagnosis of HIV positive individuals by: I Ensure access to treatment for all unin- sured persons with HIV in the U.S. and en- L 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 RESPONSE -- BUILDING THE CAPACITY OF 4 APPENDIX 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 standards. I 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 Preparedness 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 incorporates both federal funds and state I 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 Volunteer 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 funding and implementing the authority I 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 training and curricula, and incorporate I 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- tion and acquisition of needed items. I 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 and treatment in public health emergencies I 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 public health departments to facilitate the I 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 1 KaiserEDU.org. “U.S. Health Care Costs: Back- 8 Lambrew J.M. “A Wellness Trust to Prioritize Dis- ground Brief.” Kaiser Family Foundation. ease Prevention.” A Hamilton Project Discussion <http://www.kaiseredu.org/topics_im.asp?imID= Project. April 2007. 1&parentID=61&id=358> (accessed January 10, <http://www.brookings.edu/papers/2007/04useco- 2008). nomics_lambrew.aspx> (accessed October 1, 2008). 2 Essential Public Health Services Work Group of 9 The Wellness Trust has been proposed as legisla- the Core Public Health Functions Steering Com- tion, U.S. Senate Bill S.3674 (proposed October mittee, 1994. 1, 2008). 3 Based on 2005 spending levels. The analysis ex- 10 U.S. House. Committee on Energy and Com- cluded non-governmental spending, only exam- merce. Compilation of Selected Acts Within the Juris- ined health department budgets, and excluded diction of the Committee on Energy and Commerce: personal services funding to the extent possible. Health Law, as Amended Through December 31, Local spending information was based on data 2004. 109th Cong., 1st Sess. August 2005. Wash- from the National Association of City and County ington: U.S. GPO, 2001. v, 1340 p. Committee Health Officials (NACCHO) for the 2005 National Print 107-J. GPO#: Y4.C73/8:107-J. ISBN: Profile of Local Health Departments. State spending 0160508932. LCCN: 96644580. LC CALL#: information was from Trust for America’s Health, KF3821.A29 U55 and LL Micro CIS 2001-H362-7 Shortchanging America’s Health 2006: A State-By-State / 2001-H362-10. <http://loc.gov/law/find/com- Look At How Federal Public Health Dollars Are Spent, pilations.html> (accessed October 1, 2008). Washington, DC: 2006. Federal spending informa- 11 Jacobson, M.H. and K.D. Brownell. “Small Taxes tion was from the 2005 federal U.S. budgets for the on Soft Drinks and Snack Foods to Promote Centers for Disease Control and Prevention Health.” American Journal of Public Health 90, no. (CDC), the Health Resources and Services Admin- 6 (2000): 854-857. istration (HRSA), the Substance Abuse and Mental 12 Garson, A. and C.L. Engelhard. “Attacking Obe- Health Services Administration (SAMHSA), the sity: Lessons from Smoking.” Journal of the Federal Drug Administration (FDA), and the In- American College of Cardiology 49, no. 16 dian Health Service. (2007): 1673-1675. 4 Based on an analysis by The New York Academy 13 Nestle, M. Food politics: How the Food Industry In- of Medicine for the Trust for America’s Health fluences Nutrition and Health (California Studies in based on 2005 spending levels. Food and Culture). Berkeley: University of Califor- 5 OECD country expenditures are calculated using a nia Press. (2002). methodology called the System of Health Accounts 14 This report did not include data from the states (SHA). For information regarding how the U.S.’s of Hawaii, Rhode Island, and South Dakota, or NHEA methodology differs m from the OECD’s the District of Columbia. Populations served by SHA methodology please refer to Orosz E. “The local health departments that did not report OECD System of Health Accounts and the U.S. Na- their financial information were excluded. tional Health Account: Improving Connections Through Shared Experiences.”2005. 15 Louisiana was the only state not represented in <http://www.oecd.org/dataoecd/60/57/3810633 the analysis. 5.xls> (accessed October 1, 2008). 16 Louisiana was excluded from the total. 6 Washington State Association of Local Public 17 While other federal agencies contribute some Health Officials. “Creating a stronger public health funding towards public health activities, those ex- system: Statewide Priorities for Action.” May 25, penditures represent a relatively small proportion 2006. www.leg.wa.gov/documents/joint/ of spending and are difficult to quantify. This PHF/StatewidePriorities.pdf (accessed October 1, analysis focuses on those agencies that oversee the 2008). And, Berk & Associates. “Financing local majority of federal investment in public health. publichealth in Washington State: challenges Fi- 18 National Center for Health Statistics. Healthy People nance Committee. revised August 2006. 2000 Final Review. Hyattsville, Maryland: Public <http://www.doh.wa.gov/phip/documents/fi- Health Service. 2001. http://www.cdc.gov/ nance/reports/FinanceStudy.pdf > (accessed Octo- nchs/products/pubs/pubd/hp2k/review/high- ber 1, 2008). Note: The Washington State model lightshp2000.htm> (accessed October 1, 2008). uses a default population without defined demo- graphic characteristics. It may understate or over- 19 Ibid. state the necessary increase in public health 20 Trust for America’s Health. Public Health Leader- investment when extrapolated nationwide. ship Initiative: An Action Plan for Healthy People in 7 Berk & Associates. “Financing local public health Healthy Communities in the 21st Century. 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