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CHAPTER © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION

4

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Law, Government, and Public Health

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Decisions and actions that take place outside the sphere of government also influence the health of the public, perhaps After completing Chapter 4, learners will be proficient in deeven more than those made by our elected officials Learning, and ad© Jones & Bartlett Learning, LLC © Jones & Bartlett LLC scribing the role of law and government in promoting and protecting ministrative agencies. Private sector andSALE voluntary organizathe health of the public and inFOR identifying specific functions and NOT FOR OR DISTRIBUTION NOT SALE OR DISTRIBUTION roles of governmental public health agencies in ensuring population tions play key roles in identifying factors important for health health. Key aspects of this competency expectation include and advancing actions to promote and protect health for in• Identifying strategies used by governments to influence the dividuals and groups. Public health involves collective decihealth status of their citizens sions and actions, rather than purely personal ones; however, • Describing how various forms of law contribute to government’s © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ability to influence health it is often governmental forums that raise issues, make deciNOT• FOR SALE OR DISTRIBUTION NOT FORpriorities SALEfor OR DISTRIBUTION Describing the basic administrative law processes carried out by sions, and establish action. Many governmental public health agencies actions reflect the dual roles of government often portrayed • Identifying the various federal health agencies and describing on official governmental seals and vehicles of local public safety their general purpose and major activities agencies—to protect and to serve. As they relate to health, the • Identifying different approaches to organizing health responsibilities within state government of these Learning, two roles lies LLC in separate, often conflicting, © Jones & Bartlett Learning, LLC © Jonesgenesis & Bartlett • Describing common features of local health departments in the philosophies and legacies of government. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION This chapter will exUnited States amine how these roles are organized in the United States. This • Discussing implications of different approaches among states to carrying out public health’s roles examination particularly emphasizes the relationships among law, government, and public health, seeking answers to the folPublic health is not limited to what governmental public health lowing questions: ©this Jones & Bartlett Learning, © Jones & Bartlett Learning, LLC agencies do, although is a widely held misperception amongLLC • What are the various rolesFOR for government in serving NOT SALE OR DISTRIBUTION NOT SALE ORaspects DISTRIBUTION those inside and outside theFOR field. Still, particular of pubthe public’s health? lic health rely on government. For example, the enforcement of • What is the legal basis for public health in the United laws remains one of those governmental responsibilities imporStates? tant to the public’s health and public health practice.Yet, law and • How are public health responsibilities and roles structhe legal system important for public health purposes above © Jones & are Bartlett Learning, LLC © Jones & Bartlett Learning, tured at the federal, state, and local levels? LLC and beyond the enforcement of laws and regulations. Laws at all NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION levels of government bestow the basic powers of government To review the organization and structure of governmenand distribute these powers among various agencies, including tal public health, this chapter, unlike the history briefly traced public health agencies. Law represents governmental decisions in Chapter 1, will begin with federal public health roles and acand their underlying collective social values; it provides the basis tivities, to be followed, in turn, by those at the state and local © Jones & Bartlett © Joneslevels. & Bartlett LLC for actionsLearning, that influenceLLC the health of the public. The focusLearning, is primarily on form and structure, rather LEARNING OBJECTIVES

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importation of epidemic diseases; it evolved over time into than function. In most circumstances, it is logical for form to what is now the U.S. Public Health Service (PHS). follow function. Here, however, it is necessary to understand The power to promote health and welfare, however, did the legal and organizational framework of governmental pubnot always translate into the ability to act. The federal governlic health as part of the context for public health practice. The © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ment acquired the ability to raise significant financial resources framework established through law and governmental agencies NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION only with the authority to levy a federal tax on income, provided is a key element of the public health’s infrastructure and one by the 16th Amendment in the early 20th century. The ability of the basic building blocks of the public health system. This to raise vast sums generated the capacity to address health probstructure is a product of our uniquely American approach to lems and needs through transferring resources to state and local government. governments in various forms & of grants-in-aid. Despite its pow© Jones & Bartlett Learning, LLC © Jones Bartlett Learning, LLC AMERICAN GOVERNMENT AND PUBLIC HEALTH ers to provide for the general welfare and regulate commerce, NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION the federal government could not act directly in health matFormer Speaker of the U.S. House of Representatives, Tip ters; it could act only through states as its primary delivery sysO’Neil, frequently observed, “all politics is local.” If this is so, tem. After 1935, the power and influence of the federal public health must be considered primarily a local phenomegovernment grew rapidly through its financial influence over non, as well, because politics are embedded in public health © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC state and local programs, such as the Hospital Services and processes. After all, public health represents collective deciNOT FOR OR DISTRIBUTION FOR SALE OR DISTRIBUTION Construction (Hill-Burton) Act of 1946 and, after 1965, sions asSALE to which health outcomes are unacceptable, which fac- NOT through its emergence as a major purchaser of health care tors contribute to those outcomes, which unacceptable through Medicare and Medicaid. As for a public health presence problems will be addressed in view of resource limitations, at the federal level, the best-known and most widely respected and which participants need to be involved in addressing the federal public health agency, now © known as the for Learning, LLC problems. These are political with different Learning, view©processes, Jones & Bartlett LLC Jones & Centers Bartlett Disease Control and Prevention (CDC), notSALE established points and values being brought together determine NOT was FOR OR DISTRIBUTION NOT FORtoSALE ORwhich DISTRIBUTION until 1946.1 collective decisions will be made. All too often, the term poliThe emergence of the federal government as a major intics carries a very different connotation, one frequently assofluence in the health system displaced states from a position ciated with overtones of partisan politics. However, political they had held since before the birth of the American republic. processes are necessary and productive, and perhaps the best © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC States were sovereign powers before agreeing to share their powmeans devised by humans to meet our collective needs. NOT FOR SALE OR DISTRIBUTION NOT FORfederal SALE OR DISTRIBUTION ers with the newly established government; their soverThe public health system in the United States is a product eignty included powers over matters related to health emanating of many forces that have shaped governmental roles in health. from two general sources. First, they derived from the so-called The framers of the U.S. Constitution did not plan for the fedpolice powers of states, which provide the basis for government eral government to deal directly with health or, for that matlimit the & actions of individuals in orderLLC to control and abate ter, many other important issues.LLC The word health does not ©toJones © Jones & Bartlett Learning, Bartlett Learning, hazards and nuisances. A second source for state health powers even appear in that famous document, relegating health to the NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION lay in the expectation for government to serve those individugroup of powers reserved to the states or the people. The als unable to provide for themselves. This expectation had its Constitution explicitly authorized the federal government to roots in the Elizabethan Poor Laws and carried over to states in promote and provide for the general welfare (in the Preamble the new American form of government. Despite this common and Article I, Section 8) and to regulate commerce (also in Jones & Bartlett LLCstates assumed these roles quite © Jones & Bartlett heritage, differently and at dif- Learning, LLC Article I, Section 8). Federal © powers evolved slowly in theLearning, area NOT FOR OR DISTRIBUTION FOR SALE OR DISTRIBUTION ferent points in time because the evolution of statesSALE themselves of health on the basis of theseNOT explicit powers and subsequent during the 19th century took place unevenly. U.S. Supreme Court decisions that broadened federal authorStates developed structures and organizations needed to ity by determining that additional powers are implied in the exuse their police powers to protect citizens from communicaplicit language of the Constitution. ble diseases and©environmental hazards,Learning, primarily from The initial duties to international affairs and in© Jones & regulate Bartlett Learning, LLC Jones & Bartlett LLC wastes, water, and food. State health agencies developed first terstate commerce led the federal government to concentrate NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION in Massachusetts, then across the country, during the latter its efforts on preventing the importation of epidemics and ashalf of the 19th century. When federal grants became available, sisting states and localities, upon request, with their episodic especially after 1935, states eagerly sought out federal funding needs for communicable disease control. The earliest federal for maternal and child health services, public health laborahealth unit, the Marine Hospital Service, was established in © Jones Bartlett Learning, LLC and partly to prevent ©tories, Jones Bartlett Learning, LLC In so doing, and & other basic public health programs. 1798,&partly to serve merchant seamen

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American Government and Public Health

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states surrendered some of their autonomy over health issues. system in the United States. However, after about 1875 when Priorities were increasingly dictated by federal grants tied to states became more extensively involved, the relative role of specific programs and services. It is fair to say that the grantormunicipal governments began to erode. Both local and state governments were overwhelmed by the availability of federal grantee arrangement has never been fully satisfactory to either © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC funding in comparison with their own resources, finding it party, and the results in terms of health, welfare, education, NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION easier to take what they could get from the federal governand environmental policy suggest that better frameworks may ment rather than generating their own revenue to finance be possible. needed services. States possess the ultimate authority to create the politiMany forces have been at work to alter the initial relacal subunits that provide various services to the residents of a tionships levels Learning, of governmentLLC for health particular jurisdiction. In this manner, counties, © Jones & Bartlett Learning, LLC cities, and © among Jonesthe&three Bartlett roles, including other forms of municipalities, townships, boroughs, parishes, NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION and the like are established. Special-purpose districts for every • Gradual expansion and maturation of the federal govconceivable purpose—from library services and mosquito conernment trol to emergency medical services and education—have also • Staggered addition of new states and variability in the abounded. The powers delegated to or authorized for all of maturation of state governments © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC these local jurisdictions are established by state legislatures for • Population growth and shifts over time NOT FOR SALE DISTRIBUTION NOT healthOR and other purposes. Although many big-city health de- FOR SALE OR DISTRIBUTION • Ability of the various levels of government to raise revpartments were established prior to the establishment of their enues commensurate with their expanding needs respective state health agencies, states are free to use a variety • Growth of science and technology as tools for addressof approaches to structuring public health roles at the local ing public health and medical care needs level. Because most© states use the&county formLearning, of subdividingLLC Jones Bartlett © Jones & Bartlett Learning, LLC • Rapid growth of the U.S. economy the state, counties NOT becameFOR the primary NOT FOR SALE DISTRIBUTION SALElocal ORgovernmental DISTRIBUTION • Expectations and needs of American societyOR for various jurisdictions with health roles after 1900. services from their government3,4 State constitutions and statutes impart the authority for The last of these factors is perhaps the most important. For local governments to influence health. This authority comes in the first 150 years of U.S. history, there was little expectation two forms: those responsibilities of the state specifically dele© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC that the federal government should intervene in the health and gated to local governments and additional authorities allowed NOT FOR SALE OR DISTRIBUTION FOR SALEThe OR DISTRIBUTION through home rule powers. Home rule options permit local welfare NOT needs of its citizenry. massive need and economic jurisdictions to enact a local constitution or charter and to turmoil of the Great Depression years drastically altered this take on additional authority and powers, such as the ability longstanding value as Americans began to turn to government to levy taxes for local public health services and activities. to help deal with current needs and future uncertainties. Counties generally carry complex public health network that exists today © Jones & Bartlett Learning, LLCout duties delegated by the©state. Jones & The Bartlett Learning, LLC More than two thirds of U.S. counties have a county commisevolved slowly, with many different shifts in relative roles and NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION sion form of government, with anywhere from 2 to 50 elected influence. Economic considerations and societal expectations, county commissioners (supervisors, judges, and other titles both reaching a critical point in the 1930s, set the tone for the 2 are also used). These commissions carry out both legislative rest of the 20th century. In general, power and influence were and executive branch functions, although they share admininitially greatest at the local level, residing there until states Jones Bartlett © machinery Jones &toBartlett Learning, LLC istrative authority©with other & local elected Learning, officials, suchLLCbegan to develop their own carry out their poNOT FOR SALEas OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION as county clerks, assessors, treasurers, prosecuting attorneys, lice power and welfare roles. States then served the primary sheriffs, and coroners. Some counties—generally, the more locus for these health roles until the federal government began populous ones—have a county administrator accountable to to use its vast resource potential to meet changing public exelected commissioners, and a small number of counties (less pectations in the 1930s. Federal grant programs for public than 5%) have an elected county executive. Elected county exhealth and, eventually, personal healthcare service programs © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ecutives often have veto power over the county legislative body; soon drove state actions, especially the 1960s. It was then NOT FOR SALE OR DISTRIBUTION NOT FOR SALE ORafter DISTRIBUTION home rule jurisdictions are more likely to have an elected that several new federal health and social service programs county executive than are other counties. were targeted directly to local governments, bypassing states. Local governments in U.S. cities were first on the scene in At the same time, a new federal-state partnership for the medterms of public health activities, as noted in Chapter 1. Big-city ically indigent (Medicaid) was established to address the na© Jones & Bartlett Learning, © Jonestional & Bartlett Learning, LLCof the medically indigent. health agencies remain anLLC important force in the public health policy concern over the plight

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Political and philosophical shifts since about 1980 are alRights intended to protect the rights of individuals from abuses tering roles once again.3 Debates over federal versus state roles by their government. States, in turn, have developed their own continued throughout the decades between 1980 and 2010, state constitutions, often patterned after the federal frameinitially resulting in some diminution of federal influence and work, although state constitutions tend to be more clear and © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC enhancement of state influence. However, there has been an exspecific in their language, leaving less room and need for juNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION pansion of the federal role in the health reform legislation endicial interpretation. State constitutions provide the broad acted in 2010. In the end, the federal government has acquired framework from which states determine which activities will the ability to influence the health system through its fiscal musbe undertaken and how those activities will be organized and cle power, as well as its research, regulatory, technical assisfunded. These decisions and actions come in the form of state tance, and© training roles. statutes. Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Statutory (legislatively based) law includes all of the acts NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION PUBLIC HEALTH LAW and statutes enacted by Congress and the various state and local legislative bodies. This collection of law represents a wide One of the chief organizing forces for public health lies in range of governmental policy choices, including the system of law. Law has many purposes in the modern world, and many of these are evident in public health laws. • Simple of preferencesLLC in favor of a particu© Jones & Bartlett Learning, LLC © Jones & expressions Bartlett Learning, Unfortunately, there is no one repository where the entire body lar policy or service (such as the value of home visits by NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION of law, even the body of public health law, can be found. This public health nurses) has occurred because laws are products of the legal system, • Authorizations for specific programs (such as the auwhich, in the United States, includes a federal system and 50 thority for local governments to license restaurants) separate state legal systems. These developed at different times • Mandates or requirements for an activity to occur or, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC in response to somewhat different circumstances and issues. alternatively, to be prohibited (such as requiring all newCommon to each is some form of aFOR state constitution, NOTmetabolic FOR SALE NOT SALE ORa conDISTRIBUTION borns to be screened for specific diseasesOR or DISTRIBUTION siderable amount of legislation, and a substantial body of juprohibiting smoking in public places) dicial decisions. If there is any road map through this maze, • Providing resources for specific purposes (such as the it lies in the federal and state constitutions, which establish distribution of medications to patients with acquired the basic framework dividing governmental powers among the immune deficiency syndrome) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC various branches of government in ways that allow each to NOT FOR SALE OR DISTRIBUTION NOT FOR ORtoDISTRIBUTION If the legislative intent is forSALE something occur, the most create its own laws. effective approaches are generally to require or prohibit an As a result, four different types of law can be distinguished activity. by virtue of their form or authority: The basic requirement for statutory-based laws is that they • Constitutionally based law be consistent with the U.S. Constitution © Jones & Bartlett Learning, LLC ©must Jones & Bartlett Learning, LLC and, for state • Legislatively based law and local statutes, with state constitutions as well. State laws NOT FOR• SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Administratively based law also establish the various subunits of the state and delineate • Judicially based law their responsibilities for carrying out state mandates, as well as the limits of what they can do. At the local level, the legislative This framework still allows latitude for judicial interprebodies of these subunits (e.g., city councils and county comtation and oversight. A brief description of each of these forms © Jones & Bartlett Learning, LLC enact ordinances and statutes © Jones Bartlett missions) setting & forth the du- Learning, LLC of law follows. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ties and authorizations of local government and its agencies. Types of Law Laws affecting public health are created at all levels in this hierarchy, but especially at the state and local levels. Among other Constitutional law is ultimately derived from the U.S. Conpurposes, these laws establish state and local boards of health stitution, the legal foundation of the nation, in which the powand health departments, delineate the responsibilities of these ers, duties,©and limits of the federal government are established. Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC agencies, including their programs and budgets, and establish States basically gave up certain powers (e.g., defense, foreign NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION health-related laws and requirements. Many of these laws are diplomacy, printing money), ceding these to the federal govenforced by governmental agencies. ernment while retaining all other powers and duties. Health is Administrative law is law promulgated by administrative not one of those powers explicitly bestowed upon the federal agencies within the executive branch of government. Rather government. The federal constitution also included a Bill of

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Public Health Law

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cumstances, its use is a duty, rather than a matter of choice, althan enact statutes that include extensive details of a profesthough its form is left to the discretion of the user. sional or technical nature and to allow greater flexibility in The courts have upheld laws that appear to limit severely or their design and subsequent revision, administrative agencies restrict the rights of individuals where these were found to be are provided with the authority to establish law through rule© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC reasonable, rather than arbitrary and capricious attempts to acmaking processes. These rules, administrative law, carry the NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION complish government’s ends. The state’s police power is not unforce of law and represent a unique situation in which legislalimited, however. Interference with individual liberties and the tive, judicial, and executive powers are carried out by one taking of personal property are considerations that must be balagency. Administrative agencies include cabinet-level departanced on a case-by-case basis. At issue is whether the public inments, as well as other boards, commissions, and the like that terest in©achieving health Learning, goal outweighsLLC the public are through an enactment of the legislative © granted Jonesthis & power Bartlett Learning, LLC Jonesa&public Bartlett interest in protecting civil liberties. Public health laws requiring body. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION vaccinations or immunizations to protect the community The fourth type of law is judicial law, also known as comhave generally withstood legal challenges claiming that they inmon law. This includes a wide range of tradition, legal custom, fringed upon the rights of individuals to make their own health and previous decisions of federal and state courts. To ensure fairdecisions. A precedent-setting judicial opinion upheld a ness and consistency, previous decisions are used to guide judg© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Massachusetts ordinance authorizing local boards of health to ments on similar disputes. This form of law becomes especially NOT FOR SALE ORinDISTRIBUTION NOT SALE OR DISTRIBUTION require vaccinations for smallpox to be administered to resiimportant areas in which laws have not been codified by leg- FOR dents if deemed necessary by the local boards.5 Such decisions islative bodies. In public health, nuisances (unsanitary, noxious, argue that laws that place the common good ahead of the comor otherwise potentially dangerous circumstances) are one such peting rights of individuals should govern society. Similarly, area in which few legislative bodies have specified exactly what of the & state to appropriate an does and what does© not constitute public health nuisance. InLLCcourts have weighed the power Jones & aBartlett Learning, © Jones Bartlett Learning, LLC individual’s property or limit the individual’s use ofOR it if the best this situation, the common law for nuisances derived from NOT FOR SALE DISTRIBUTION NOT FOR SALE ORis DISTRIBUTION interests of the community make such an action desirable. In previous judicial decisions. These determine under what cirsome circumstances, equitable compensation must be provided. cumstances and for what specific conditions a public health ofIssues of community interest and fair compensation are comficial can take action, as well as the actions that can be taken. monly encountered in dealing with public health nuisances © Jonesof&Public Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Purposes Health Law in which an individual’s private property can be found to be NOT FOR SALE OR DISTRIBUTION FOR SALE OR DISTRIBUTION harmfulNOT to others. Two broad purposes for public health law can be described: proThe various forms of law and the changing nature of the tecting and promoting health and ensuring the protection of relationships among the three levels of government have crerights of individuals in the processes used to protect and proated a patchwork of public health laws. Despite its relatively mote health. Public health powers ultimately derive from the constitutionally based powers, U.S. Constitution, which bestows © Jones & Bartlett Learning, LLC the authority to regulate©comJoneslimited & Bartlett Learning, LLC the federal government can preempt state and local government merce and provide for the general welfare, and from the various NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION action in key areas of public health regulation involving commerce and aspects state constitutions, which often provide clear but broad auof communicable disease control. States also have authority thorities, based largely on the police power of the state. States to preempt local government actions in virtually all areas of often have reasonably well-defined public health codes. However, public health activity. Although this legal framework allows there is considerable diversity in their content and scope, de© Jones & Bartlett © Jones & Bartlett LLC of authorities andLearning, responspite similarities in their basic sources of powerLearning, and authority.LLCfor a clear and rational delineation NOT FOR SALE OR DISTRIBUTION NOTlaws FOR SALEand ORenforced DISTRIBUTION sibilities, a quite variable set of arrangements has arisen. Often, Many public health are enacted under the higher level of government chooses not to exercise its full what is known as the state’s “police power.” This is a broad conauthority and shifts that authority to a lower level of governcept that encompasses the functions historically undertaken by ment. This can be accomplished in some instances by delegatgovernments in protecting the health, safety, welfare, and gening or requiring, and other instances by authorizing eral well-being of their citizens. A wide variety of laws derive © Jones & Bartlett Learning, LLC © Jones &inBartlett Learning, LLC (with incentives), lower SALE level of government to exercise authorfrom policeSALE power ofOR the DISTRIBUTION state, a power that is considered NOTtheFOR NOTtheFOR OR DISTRIBUTION ities of the higher level. This has made for a complex set of one of the least limitable of all governmental powers. The porelationships among the three levels of government and for lice power of the state can be vested in an administrative agency, 50 variations of the theme to be played in the 50 states. These such as a state health agency, which becomes accountable for the relationships and their impact on the form and structure of manner in which these responsibilities are executed. In these cir-

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quent sections of this chapter. Federal Health Agencies There have been many critiques of the statutory basis of The PHS serves as the focal point for health concerns at the public health in the United States. A common one is that pubfederal level. Although there have © been frequent © Jones & Bartlett Learning, LLC Jones & reorganizaBartlett Learning, LLC lic health law, not unlike law affecting other areas of society, tions affecting the structure of PHS and its placement within NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION simply has not kept pace with the rapid and extensive changes the massive Department of Health and Human Services in science and technology. Laws have been enacted at different (DHHS), the restructuring completed in 1996 was the most points in time in response to different conditions and cirsignificant in recent decades. The changes were undertaken cumstances. These laws have often been enacted with little conas part of the federal Reinvention of Government Initiative sideration© as Jones to their consistency with previous statutes & Bartlett Learning, LLCand © Jones & Bartlett Learning, LLC to bring expertise in public health and science closer to the their overall impact on the body of public health law. For exNOT FOR SALE OR DISTRIBUTION NOT SALE ORtheDISTRIBUTION Secretary of DHHS. In FOR the restructuring, line authority ample, many states have different statutes and legal frameof the Assistant Secretary for Health over the various agencies works for similar risks, such as general communicable diseases, within PHS was abolished, with those agencies now reporting sexually transmitted diseases (STDs), and human immunoddirectly to the Secretary of DHHS, as illustrated in Figure 4–1. eficiency virus infections. Confidentiality and privacy proviAssistant Secretary for Health became © Jones & Bartlett Learning, LLC ©The Jones & Bartlett Learning, LLCthe head of the sions, which trace their origins to the vow in the Hippocratic Office of Public Health and Science (OPHS), a new division NOT FOR SALE OR DISTRIBUTION oath not to reveal patient’s secrets, are often inconsistent from NOT FOR SALE OR DISTRIBUTION reporting to the Secretary that also includes the Office of the law to law, and enforcement provisions vary as well. Beyond Surgeon General. Each of the former PHS agencies became a these concerns, public health laws often lack clear statements full DHHS operating division. These eight operating agenof purpose or mission and are not linked to public health core cies, the OPHS, and the regional health administrators for the functions and essential public services. © health Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 10 federal regions of the country now constitute the PHS. In In view of these criticisms, recommendations NOT SALE OR DISTRIBUTION NOT FOR SALE have OR been DISTRIBUTION effect, PHS has become a functional ratherFOR than an organizaadvanced calling for a complete overhaul and recodification tional unit of DHHS. In 2003, several activities related to of public health law. Recommendations for improvement of emergency preparedness and response were moved into the the public health codes often call for newly established Department of Homeland Security (see Chapter 5). An Office of Public Emergency Prepared• Stronger links with the overallLearning, mission and core © Jones & Bartlett LLCfunc© Jones & Health Bartlett Learning, LLC ness and Response remained DHHS OR to coordinate biotertions of public health NOT FOR SALE OR DISTRIBUTION NOT FORatSALE DISTRIBUTION rorism and other public health emergency activities managed • Uniform structures for similar programs and services by various PHS agencies. • Confidentiality provisions to be reviewed and made The PHS agencies address a wide range of public health more consistent activities, from research and training to primary care and • Clarification of police power responsibilities to deal with © Jones &unusual Bartlett Learning, LLC ©health Jones & Bartlett Learning, LLC protection, as described in Table 4–1. The key PHS agenhealth risks and threats NOT FOR• SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION cies are Greater emphasis on the least restrictive means necessary to achieve the law’s intent through use of interme• Health Resources and Services Administration (HRSA) diate sanctions and compulsive measures, based on • Indian Health Service proven effectiveness • CDC • Fairer and more consistent enforcement and adminis© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC • National Institutes of Health (NIH) trative practices NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Food and Drug Administration Although these recommendations have been advanced for • Substance Abuse and Mental Health Services Adminiseveral decades, little progress has been made at either the fedstration eral or state level. At times, states have sought to recodify pub• Agency for Toxic Substances and Disease Registry lic health © statutes by relocating their Learning, placement in the statute • Agency for©Healthcare Research and Quality (AHRQ) Jones & Bartlett LLC Jones & Bartlett Learning, LLC books, rather than dealing with the more basic issues of reNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION PHS agencies actually represent only a small part of viewing the scope and allocation of their public health reDHHS. Other important operating divisions within DHHS sponsibilities so that these are clearly presented and assigned include the Administration for Children and Families, the among the various levels of government. The intricacies of Health Care Financing Administration (HCFA), and the Office public health law often help drive the inner workings of fed© Jones & Bartlett Learning, LLC © & Bartlett Learning, LLC there are sevofJones the Assistant Secretary for Aging. In addition, eral, state, and local public health agencies. We will now turn NOT FOR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION eral administrative and support units within DHHS for manto the SALE form andOR structure of these agencies.

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FIGURE 4–1 U.S. Department of Health and Human Services organization chart, 2010. © Jones & Bartlett Learning, LLC The Secretary NOT FOR SALE OR DISTRIBUTION

Office of Intergovernmental Affairs and Regional Representatives

Deputy Secretary

Office of Public

© Jones & Bartlett Learning, LLC Program Support Center NOT FOR SALE OR DISTRIBUTION Office of the Assistant Secretary for Financial Resources (ASFR)

© Jones &

The Executive Secretariat

Office of the Agency for Toxic General Counsel © Jones & Bartlett Learning, LLC Substances and (OGC) Disease Registry NOT FOR SALE OR DISTRIBUTION (ATSDR)* Office of Medicare Hearings and Centers for Disease Appeals (OMHA) Control and Prevention (CDC)*

and Science for © Jones &Health Bartlett Learning,Administration LLC (OPHS)* Children and NOT FOR SALE OR DISTRIBUTION Families (ACF) Office of the Assistant Secretary for Administration (ASA)

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Chief of Staff

Administration on Aging (AOA)

Office for Civil © Jones & Bartlett Learning, LLC Rights (OCR) Food and Drug FOR SALE OR DISTRIBUTION Administration

Centers for Medicare NOT and Medicaid Services (CMS) Agency for Healthcare Research and Quality (AHRQ)* Bartlett Learning,

LLC

(FDA)* Indian Health Service (IHS)*

Office of the Inspector General (IG)

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Office of the Assistant of Global NOTOffice FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Secretary for Planning Health Affairs Health Resources National Institutes and Evaluation (OGHA)* and Services of Health (ASPE) Administration (NIH)* (HRSA)* Departmental Office of the Assistant Appeals Board Secretary for (DAB) Substance Abuse and© Jones & Bartlett Learning, © Jones &Preparedness Bartlett Learning, LLC LLC and Mental Health Services Response (ASPR)* NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Administration Office of the National (SAMHSA)* Coordinator for Health Office of the Assistant Information Technology Secretary for (ONC) Legislation (ASL) *Designates components of Office of the Assistant Center for Faith-Based the Public Health Service © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Secretary for Public and Community Affairs (ASPA) Initiatives NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION(CFBCI)

Source: From U.S. Department of Health and Human Services, 2010.

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agement and the budget, intergovernmental affairs, legal coununderestimated in terms of the level and proportion of their resel, civil rights, the inspector general, departmental appeals, sources© devoted to health purposes.Learning, Health-specific agencies at © Jones & Bartlett Learning, LLC Jones & Bartlett LLC public andDISTRIBUTION planning and evaluation. the federal level are a SALE relativelyOR newDISTRIBUTION phenomenon. PHS itself NOTaffairs, FORlegislation, SALE OR NOT FOR Beyond DHHS, health responsibilities have been assigned remained a unit of the Treasury Department until 1944, and to several other federal agencies, including the federal Enthe first cabinet-level federal human services agency of any vironmental Protection Agency (EPA) and the Departments kind was the Federal Security Agency in 1939. This historical of Homeland Security, Education, Agriculture, Defense, Transtrivia demonstrates that federal powers and authority in health © Jones & Bartlett © imJonesand & public Bartlett LLC portation,Learning, and Veterans LLC Affairs, just to name a few. The healthLearning, are a relatively recent phenomenon in U.S. NOT FOR SALE ORof DISTRIBUTION NOT SALE OR DISTRIBUTION portance some of these other federal agencies should not be FOR history.

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The federal government is the largest purchaser of healthfor federal health programs. Although one fourth of the fedrelated services, with spending on health representing more eral budget supports health activities, the major share is spent than one fourth of the total federal budget. Figure 4–2 comon Medicare and Medicaid. These and other entitlement propares total national health expenditures with health expendigrams constitute two thirds of the federal budget; this spend© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC tures attributed to the federal government and to state local ing is mandatory and cannot be easily controlled. The NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION governments. Health expenditures constituted nearly 26% of remaining one third represents discretionary spending; half of total federal expenditures in 2007, up from 12% in 1980, and this is related to national defense purposes. Spending for disonly 3% in 1960 (Figure 4–3). Escalating costs for healthcare cretionary programs is more readily controlled. Nondefense services seriously constrain efforts to reduce the federal budget discretionary spending for health purposes competes with a deficit, and is little or political supportLLC for addiwide array of programs, including education, training, sci©there Jones & public Bartlett Learning, © Jones & Bartlett Learning, LLC tional taxes for health purposes. ence, technology, housing, transportation, and foreign aid. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION It is no simple task to describe the federal budget develDespite a small increase as a result of national terrorism preopment and approval process that determines funding levels paredness initiatives, nondefense discretionary funding for

© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION TABLE 4–1 U.S. Public Health Service Agencies Health Resources and Services Administration (HRSA)

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HRSA helps provide health resources for medically underserved populations. The main operating units of HRSA are the Bureau of PrimaryLearning, Health Care, Bureau and Child& Bureau, © Jones & Bartlett LLCof Health Professions, Maternal © Jones Bartlett Learning, LLC and the HIV/AIDS Bureau. A nationwide network of 643 community and migrant health centers, plus 144 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION primary care programs for the homeless and residents of public housing, serve 8.1 million Americans each year. HRSA also works to build the health care workforce and maintains the National Health Service Corps. The agency provides services to people with AIDS through the Ryan White Care Act programs. It oversees the organ transplantation system and works to decrease infant mortality and improve maternal and child health. HRSA was established in 1982 by bringing together several existing programs. HRSA has more than Bartlett Learning, LLC in Rockville, Maryland. © Jones & Bartlett Learning, LLC 1,850 employees at its headquarters

© Jones & NOT FOR SALE OR DISTRIBUTION NOTIndians FORand SALE OR DISTRIBUTION Indian Health IHS is responsible for providing federal health services to American Alaska Natives. The proviService (IHS)

sion of health services to members of federally recognized tribes grew out of the special government-togovernment relationship between the federal government and Indian tribes. This relationship, established in 1787, is based on Article I, Section 8 of the Constitution, and has been given form and substance by numerous treaties, laws, Supreme Court decisions, and Executive Orders. IHS is the principal federal health care provider and&itsBartlett goal is to raise their health status © Jones & Bartlett Learning, LLCand health advocate for Indian © people, Jones Learning, LLCto the highest possible level. IHS currently provides health services to approximately 1.9 million American Indians and NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Alaska Natives who belong to more than 564 federally recognized tribes in 35 states. IHS was established in 1924; its mission was transferred from the Interior Department in 1955. Agency headquarters are in Rockville, Maryland. IHS has more than 15,000 employees. Centers for Disease Control and Prevention (CDC)

Working with states and other partners, CDC provides a system of health surveillance to monitor and prevent disease outbreaks, including bioterrorism events and threats, and maintains health statistics. Learning, LLC © Jones & Bartlett Learning, LLC ©national Jones & Bartlett CDC also provides for immunization services, supports research into disease and injury prevention, and NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION guards against international disease transmission, with personnel stationed in more than 54 foreign countries. CDC was established in 1946; its headquarters are in Atlanta, Georgia. CDC has 9,000 employees.

National Institutes of Health (NIH)

Begun as a one-room Laboratory of Hygiene in 1887, NIH today is one of the world’s foremost medical research centers and the federal focal point for health research. NIH is the steward of medical and behavioral research forLearning, the nation. Its mission knowledge about theLearning, nature and be-LLC © Jones & Bartlett LLC is science in pursuit of fundamental © Jones & Bartlett havior of living systems and the application of that knowledge to extend healthy life and reduce the burdens NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION of illness and disability. In realizing its goals, NIH provides leadership and direction to programs designed to improve the health of the nation by conducting and supporting research in the causes, diagnosis, prevention, and cure of human diseases; in the processes of human growth and development; in the biological effects of environmental contaminants; in the understanding of mental, addictive and physical disorders; and in directing programs for the collection, dissemination, and exchange of information in medicine and health,

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TABLE 4–1 U.S. Public Health Service Agencies (continued) National Institutes including the development and support of medical libraries and the training of medical andLearning, other ©ofJones & Bartlett Learning, LLC © Jones &librarians Bartlett LLC Health (NIH) health information specialists. Alhough the majority of NIH resources sponsor external research, there is also NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION (continued) a large in-house research program. NIH includes 27 separate health institutes and centers; its headquarters are in Bethesda, Maryland. NIH has more than 19,000 employees. Food and Drug Administration (FDA)

FDA ensures that the food we eat is safe and wholesome, that the cosmetics we use won’t harm us, and that medicines, medical devices, and radiation-transmitting products such as microwave ovens are safe and effecFDA also oversees feed and drugs for pets and farm animals. Authorized by Congress to enforce the © Jones & Bartletttive. Learning, LLC © Jones & Bartlett Learning, LLC Federal Food, Drug, and Cosmetic Act and several other public health laws, the agency monitors the manuNOT FOR SALE OR DISTRIBUTION NOT FOR SALE ORatDISTRIBUTION facture, import, transport, storage, and sale of $1 trillion worth of goods annually, a cost to taxpayers of about $3 a person. FDA has over 11,000 employees, located in 167 U.S. cities. Among its staff, FDA has chemists, microbiologists, and other scientists, as well as investigators and inspectors who visit 16,000 facilities a year as part of their oversight of the businesses that FDA regulates. FDA, established in 1906, has its headquarters in Rockville, Maryland.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Substance Abuse and SAMHSA was established by Congress under Public Law 102-321 on October 1, 1992, to strengthen the NOT FOR SALEMental OR DISTRIBUTION NOTprevention, FOR SALE ORandDISTRIBUTION Health nation’s healthcare capacity to provide diagnosis, treatment services for substance abuse Services Administration (SAMHSA)

and mental illnesses. SAMHSA works in partnership with states, communities, and private organizations to address the needs of people with substance abuse and mental illnesses as well as the community risk factors that contribute to these illnesses. SAMHSA serves as the umbrella under which substance abuse and mental health service centers are housed, including the Center for Mental Health Services (CMHS), the Center for Substance Abuse Prevention (CSAP), and the Center for Substance Abuse©Treatment SAMHSA also © Jones & Bartlett Learning, LLC Jones(CSAT). & Bartlett Learning, LLC houses the Office of the DISTRIBUTION Administrator, the Office of Applied Studies, andNOT the Office of Program FOR SALEServices. OR DISTRIBUTION NOT FOR SALE OR SAMHSA headquarters are in Rockville, Maryland; the agency has about 600 employees.

Agency for Toxic Working with states and other federal agencies, ATSDR seeks to prevent exposure to hazardous substances Substances and from waste sites. The agency conducts public health assessments, health studies, surveillance activities, and Disease Registry health education training in communities around waste sites on the U.S. Environmental Protection Agency’s (ATSDR) PrioritiesLLC List. ATSDR also has developed toxicologic profiles of hazardous chemicals found at these © Jones & BartlettNational Learning, © Jones & Bartlett Learning, LLC sites. The agency is closely associated administratively with CDC; its headquarters are also in Atlanta, NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Georgia. ATSDR has more than 400 employees. Agency for Health Care Research and Quality (AHRQ)

AHRQ supports cross-cutting research on healthcare systems, healthcare quality and cost issues, and effectiveness of medical treatments. Formerly known as the Agency for Health Care Policy and Research, AHRQ was established in 1989, assuming broadened responsibilities of its predecessor agency, the National Center for Health Services Research and Health Care Technology Assessment. The agency has about LLC & Maryland. Bartlett Learning, LLC 300 employees; its headquarters © areJones in Rockville,

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health purposes has declined as a proportion of all federal 13 annual appropriations bills. In recent years federal law has © Jones & Bartlett Learning, LLCimposed a cap on total annual © Jones & Bartlett LLC spending. discretionary spendingLearning, and reFORincreased SALE OR DISTRIBUTION NOT FOR SALEhealth OR programs DISTRIBUTION Decisions authorizing and funding are quires that spending cutsNOT must offset mandatory made in an annual budget approval process. The current spending or new discretionary programs. This budgetary enprocess is a complex one that establishes ceilings for broad catvironment presents major challenges for new public health proegories of expenditures and then reconciles individual programs and, not infrequently, threatens continued funding for grams and funding levels within those ceilings in omnibus programs have been operatingLearning, for decades. LLC © Jones & Bartlett Learning, LLC © that Jones & Bartlett budget reconciliation acts. For discretionary programs, The organization of federal health responsibilities within NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Congress must act each year to provide spending authority. For DHHS is quite complex fiscally and operationally. In federal mandatory programs, Congress may act to change the spendfiscal year 2011, the overall DHHS budget is about $900 biling that current laws require. The result is a mixture of sublion.6 DHHS has nearly 73,000 employees and is the largest stantive decisions as to which programs will be authorized and grant-making agency in the federal government, with some © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, what they will be authorized to do, together with budget deci60,000 grants each year. DHHSLLC manages more than 300 proNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR sions as to the level of resources to be made available through grams through its DISTRIBUTION 11 operating divisions. The major share of

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the 1990 and 2000 processes related to the public health system; that obgovernment expenditures for health-related purposes, United States, 1980–2008. jective called for 90% of the population to be served by a local public © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC $2,500 health agency (LPHA) that was ef$2,339 Total NationalNOT Health Expenditures NOT FOR SALE OR DISTRIBUTION FOR SALE OR DISTRIBUTION fectively carrying out public health’s Federal Health Expenditures core functions.7 Current estimates State/Local Health Expenditures are that about 95% of the U.S. pop$2,000 ulation is served by an LPHA func© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC tioning at some level of capability. Baseline data on how many local NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION $1,500 agencies were effectively carrying $1,353 out the core functions were not available when this objective was established in 1990. Several studies of © Jones &$1,000 Bartlett Learning, LLC © Jones & Bartlett Learning, LLC core function-related performance $817 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR in DISTRIBUTION $714 the 1990s suggest that the nation fell far short of achieving its year $500 2000 target. $418 $290 PHS agencies have promoted $253 $194 $179 greater © useJones of performance mea- Learning, LLC © Jones &$93Bartlett Learning, LLC & Bartlett $72 $35 sures inNOT key federal health proFOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION $0 grams, including immunizations, 1980 1990 2000 2008 tuberculosis control, STDs, subSource: Data from Centers for Disease Control and Prevention, National Center for Health Statistics. stance abuse, and mental health Health, United States, 2009. Hyattsville, MD: NCHS; 2009. services. As previously described, © Jones & Bartlett Learning, LLC © Jonesfederal & Bartlett Learning, LLC grants-in-aid have long NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION been the prime strategy and mechanism by which the federal government generates state and local action toward important health the DHHS budget supports the Medicare and Medicaid proproblems. A variety of approaches to grant making have been grams within HCFA. PHS activities account for less than one over recent decades. Learning, These can be categorized by the extenth&ofBartlett the DHHSLearning, budget. In addition © Jones LLCto HCFA and the PHS ©used Jones & Bartlett LLC tent of restrictions or flexibility imparted to grantees. The agencies, DHHS also includes the Administration for Children NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION greatest flexibility and lack of requirements are associated with and Families and the Administration on Aging. revenue-sharing grants. Block grants, including those initiated Budgets for PHS operating divisions in federal fiscal year in the early 1980s, consolidate previously categorical grant pro2011 range from $32 billion for NIH to $600 million for AHRQ grams into a block that generally comes with fewer restrictions (Figure 4–4). Just over 50% of all PHS funds support NIH reJones Bartlett Learning, © Jones & Bartlett thanLLC the previous collection of categorical grants. Formula Learning, LLC search activities, and another©$32 billion & support the remainFOR SALEforOR DISTRIBUTION FOR SALE OR DISTRIBUTION grants are awarded on the basis ofNOT some predetermined ing PHS agencies with HRSANOT and CDC together accounting for mula, often based at least partly on need, which determines about $18 billion, which represents about 2% of total DHHS the level of funding for each grantee. Project grants are more resources and about 0.5% of all federal spending. limited in availability and are generally intended for a specific Since the late 1970s, the Office of Health Promotion and demonstration program or project. Disease Prevention within the Office of the Assistant Secretary © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC In the 1990s, DHHS proposed a series federal partnerfor HealthNOT has coordinated the development of the national FOR SALE OR DISTRIBUTION NOT FOR SALE ORof DISTRIBUTION ship performance grants to address some of the shortcomings agenda for public health and prevention efforts. Results of these attributed to block grants implemented in the early 1980s. At efforts are apparent in the establishment of national health that time, restrictions were relaxed for the categorical proobjectives that targeted the years 1990, 2000, 2010, and 2020 grams folded into the block grants, including the Maternal and (see Chapter 2). Only one of more than 500 objectives from $ in Billions

FIGURE 4–2 Total national health expenditures, and federal and state/local

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Child Health Block Grant and the FIGURE 4–3 National health expenditures as percent of gross domestic product Prevention Block Grant. Lessons (GDP), and federal and state/local government health expenditures as percent of learned from the previous total government expenditures, United States, 1980–2007. experience suggest the need for a © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC cautious approach to new federal NOT FOR SALE OR DISTRIBUTION NOT FOR SALE35% OR DISTRIBUTION block grant proposals. In the Total National Health Expenditures as Percentage of GDP 1980s, the new block grants inFederal Health Expenditures as Percentage of Total Federal Spending deed came with fewer strings at30% State/Local Health Expenditures as Percentage of Total State/Local Spending tached. However, they also came 26.2% at©funding that wereLearning, reJoneslevels & Bartlett LLC © Jones & Bartlett Learning, LLC 25% duced 25% from the previ22.4% OR DISTRIBUTION NOTabout FOR SALE OR DISTRIBUTION NOT FOR SALE ous arrangement. The blocking of 20% several categorical programs into 16.2% one mega grant also served to dis15.5% 14.9% 14.1% 15% sipate the constituencies for the 13.8% 12.7% © Jones & Bartlett Learning, LLC © Jones 12.3% & Bartlett Learning, LLC 12.2% categorical programs. Without ac10.6% NOT FOR SALE OR DISTRIBUTION 9.1% NOT FOR SALE OR DISTRIBUTION tive and visible constituencies ad10% vocating for programs, restoration or even maintenance 5% of previous funding levels proved difficult. In addition, the reduc© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 0% tion in reporting requirements NOT NOT FOR SALE OR DISTRIBUTION 1990 2000 FOR SALE 2007OR DISTRIBUTION 1980 made it more difficult to justify Source: Data from Centers for Disease Control and Prevention, National Center for Health Statistics. Health, budget requests. Any new federal United States, 2009. Hyattsville, MD: NCHS; 2009. approaches to overcome these obstacles will be watched closely by © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC advocates, as well as by state and NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION local public health officials. ence in the 1960s and 1970s. At that time, numerous federal In addition to being a prime strategy to influence services health and human service initiatives (such as model cities, at the state and local level, federal grants also serve to rediscommunity health centers, and community mental health tribute resources to compensate for differences in the ability of were funded directly to local governments and even states to fund and operateLLC basic health services. They have © Jones & Bartlett Learning, ©also Jonesservices) & Bartlett Learning, LLC to community-based organizations. This practice greatly conserved as a useful approach to promoting minimum standards NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION cerned state capitals and served to damage tenuous relationfor specific programs and services. For example, federal grants ships among the three levels of government. The relative for maternal and child health promoted personnel standards influence of states began to grow once again after 1980, with in state and local agencies that fostered the growth of civil servboth increasing rhetoric and federal actions restoring some ice systems across the country. Other effects on state and local Learning, © Jones &state Bartlett Learning, LLC and their health agencies. health agencies will©beJones apparent&asBartlett these are examined in theLLCpowers and resources to states NOT FOR SALE OR DISTRIBUTION Although states were finding it increasingly difficult to finance following sections. NOT FOR SALE OR DISTRIBUTION public health and medical service programs, they demanded State Health Agencies more autonomy and control over the programs they managed, including those operated in partnership with the federal Several factors place states at center stage when it comes to government. At the & same time, local governments were makhealth. The U.S. Constitution gives states primacy in safe© Jones & Bartlett Learning, LLC © Jones Bartlett Learning, LLC ing demands state SALE governments to those that states guarding the health of their From the mid-19th cenNOT FOR SALE ORcitizens. DISTRIBUTION NOTon FOR OR similar DISTRIBUTION were making on the federal government. States have found tury until the 1930s, states largely exercised that leadership themselves uncomfortably in the middle between the two role with little competition from the federal government and other levels of government. At the same time, states are one only occasional conflict with the larger cities. Federal funding step removed from both the resources needed to address the turned the tables on states after 1935, reaching its peak influ-

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states often appear unduly influenced by large, politically active lobbies representing various aspects of level budgets. the health system. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC States carry out their health reAHRQ $0.6 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION sponsibilities through many different state agencies, although the overall SAMHSA $3.7 constellation of health programs and services within all of state government is similar across states. Table 4–2 ©NIH Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC $32.2 outlines more than two dozen state NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION agencies that carry out health responCDC $10.6 sibilities or activities in a typical state. Somewhere in the maze of state agenIndian HS $5.4 cies is an identifiable lead agency for © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC health. These official health agencies NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR areDISTRIBUTION often freestanding departments HRSA $7.6 reporting to the governor of the state. In about two thirds of the states, the FDA $4.0 state health agency reports to a state board of health, although the preva- Learning, LLC &$15 Bartlett LLC © Jones & Bartlett $0 $5 © Jones $10 $20Learning, $25 $30 $35 lence of this reporting relationship is DISTRIBUTION NOT FOR SALE OR NOT FOR SALE OR DISTRIBUTION Billions declining. Another approach to the organizational placement of state Source: Data from the Fiscal Year 2011 Budget, U.S. Department of Health and Human Services, 2010. health agencies finds them within a multipurpose human service agency, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC often with the state’s social services and NOT FOR SALE OR DISTRIBUTION NOT FOR OR DISTRIBUTION needs of their citizens and the demands and expectations of substance abuse responsibilities.SALE This approach has waxed and the local citizenry. For health issues, especially those affectwaned in popularity, although its popularity increased in the ing oversight and regulation of health services and providers, 1990s with the hopes of fostering better integration of commuPublic Health Service Agencies

FIGURE 4–4 Fiscal year 2011 U.S. Public Health Service Agency program

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION TABLE 4–2 Typical State Agencies with Health Roles (Names Vary from State to State) • Department of Homeland Security • Official State Health Agency (Department of Health/Public • Department of Mental Health and Developmental Health) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Disabilities • Department of Aging • Department of Mines and Minerals NOT FOR SALE OR DISTRIBUTION • Department of AgricultureNOT FOR SALE OR DISTRIBUTION • Department of Nuclear Safety • Department of Alcoholism and Substance Abuse • Pollution Control Board • Asbestos Abatement Authority • Department of Professional Regulation • Department of Children and Family Services • Department of Public Aid • Department of Emergency and Disaster Services • Department of Rehabilitation • Department of Energy Natural Resources © Jones & and Bartlett Learning, LLC © Jones Services & Bartlett Learning, LLC • Rural Affairs Council • Environmental Protection Agencies NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • State Board of Education • Guardianship and Advocacy Commissions • State Fire Marshall • Health and Fitness Council • Department of Transportation • Health Care Cost Containment Council • State University System • Health Facilities Authority • Department of Veterans Affairs • Health Facilities Planning Board

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range, reflecting the diversity in agency responsibilities. The data nity services across the spectrum of health and social services. presented on state health agencies in this chapter are derived State health agencies are freestanding agencies in about 28 states from recent surveys of state health officials conducted by the and are part of multipurpose health and/or human services 8 ASTHO in 2005 and 2007.8–11 Figure 4–6 illustrates the variagencies in the others. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC The public official with statutory authority to carry out ability in state health agencies’ responsibilities for programs. In NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION public health laws and declare public health emergencies is gen2005, for example, 90% of the official state health agencies aderally the state health official who directs the state health deministered the Supplemental Food Program for Women, Infants, partment. In some states, however, this statutory authority and Children, vital statistics systems, public health laboratories, resides with other public officials, such as the governor or diand tobacco prevention and control programs. Less than one rector of the superagency in which the stateLLC health department half of the health&agencies administered the state Medicaid © Jones & Bartlett Learning, © state Jones Bartlett Learning, LLC isNOT a component, or with the state board of health (Figure 4–5). Program, mental health and substance abuse services, and health FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION As identified in a recent profile of state public health agenprofessional licensing. Many state health agencies administered cies compiled by the Association of State and Territorial Health programs for environmental health services, most frequently Officials (ASTHO), key activities performed by state public involving food and drinking water safety; however, only 20% of health agencies include8: the state health agencies served as the environmental regulatory © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC agency within their state, which often includes responsibility for NOT FOR SALE• OR DISTRIBUTION NOT SALE OR DISTRIBUTION Running efficient statewide prevention programs like FOR clean air, resource conservation, clean water, superfund sites, tobacco quit lines, newborn screening programs, and toxic substance control, and hazardous substances. disease surveillance. State health agency responsibilities are anything but fixed • Ensuring a basic level of community public health servin stone; they change with the times. The 1990s witnessed sevices across the regardless of the level of resourcesLLCeral changes in the public health responsibilities of state health ©state, Jones & Bartlett Learning, © Jones & Bartlett Learning, LLC or capacity ofNOT local health agencies. More state healthNOT agencies tookSALE on preparedness reFOR OR DISTRIBUTION FOR departments. SALE OR DISTRIBUTION • Providing the services of professionals with specialized sponsibilities and expanded their health planning and develskills, such as disease outbreak specialists and restauopment roles during the decade. On the other hand, fewer state rant and food service inspectors, who bring expertise health agencies were carrying out environmental health and inthat is otherwise hard to find, too expensive to employ stitutional licensing functions and some lost responsibility for © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC at a local level, or involve overseeing local public health natural disaster preparedness to state emergency management NOTfunctions. FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Collecting and analyzing statewide vital statistics, health indicators, and morbidity data to target public health threats and diseases such as cancer. © Jones & Bartlett Learning, LLC © Jones & Bartlett FIGURE 4–5 Primary statutoryLearning, public healthLLC authority in states. • Providing statewide investigations of NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION disease outbreaks, environmental Governor hazards such as chemical spills and 2% Superagency/Umbrella hurricanes, and other public health Agency Official Other 10% 8% emergencies. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC • Monitoring the use of funds and State Board NOT FOR SALE OR DISTRIBUTION NOT other resources to FOR ensure SALE they areOR DISTRIBUTION of Health 12% used effectively and equitably State Health Official throughout the state. 68% • Conducting statewide health planning, improvement, evaluation.LLC © Jones & Bartlett and Learning, © Jones & Bartlett Learning, LLC • Licensing and regulating health care, NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION food service, and other facilities. The range of responsibilities for the official state health agency varies considerably © Jones & Bartlett LLCand services. in terms ofLearning, specific programs NOT FOR SALE OR DISTRIBUTION Staffing levels and patterns also show a wide

Source: Data from Association of State and Territorial Health Officials (ASTHO). Profile of State Public Health, Volume One. Washington, DC: ASTHO; 2009.LLC © Jones & Bartlett Learning,

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FIGURE 4–6 Selected organizational responsibilities of state health agencies, 2005. © Jones & Bartlett Learning, LLC 16% NOTMedicaid FOR SALE OR DISTRIBUTION Mental health

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20%

Environmental regulation

25%

Medical examiner

© Jones & Bartlett Learning, LLC Health professional licensing NOT FOR SALE OR DISTRIBUTION

29%

Drug/alcohol abuse prevention

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35% 37%

Drinking water regulation

53%

Environmental health

76%

© Jones & Bartlett Learning, LLC Health facility regulation NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC NOT FOR SALE OR78% DISTRIBUTION

Food safety

82%

Public health laboratories

90%

Tobacco prevention

94%

© Jones & Bartlett Learning, LLC Vital statistics NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC 94% NOT FOR SALE OR DISTRIBUTION

WIC 0%

98% 10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

© Jones Learning, LLC Health Officials. Washington,©DC: Jones Bartlett Learning, LLC Source: & DataBartlett from Association of State and Territorial ASTHO; & 2006. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

advent of Medicaid and Medicare in 1965, state and local govagencies. Figure 4–7 catalogs new and emerging roles and re9 spent more for health purposes sponsibilities for state health agencies. © Jones & Bartlett Learning, LLC Notably, bioterrorism ©ernments Jonesactually & Bartlett Learning, LLC than did the federalFOR government. preparedness is the most prevalent of these NOT NOT FOR SALE and ORresponse DISTRIBUTION SALE OR DISTRIBUTION With public health responsibilities allocated differently emerging roles. across the various states, data on state health agency expendiNearly one in two states relies on regional or district oftures are both difficult to interpret and incomplete in several fices to carry out state responsibilities and to assist local health 10 important respects. These data do not allow for meaningful departments (LHDs). Staff assigned to district offices BartletttoLearning, LLC across states because of©theJones &inBartlett comparison variation responsi- Learning, LLC often provide consultation © andJones technical&assistance local OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION bilities assigned to the official stateNOT healthFOR agencySALE and those health agencies within that district especially for purposes of assigned to other state agencies. More importantly, these data medical oversight, budgetary management, inspectional acoften fail to differentiate between population-based public tivities and code enforcement, provision of education and health activities and personal health services. Also lacking is a training, and general planning and coordination for activicomposite picture resource&allocations important pubties such as emergency preparedness. More than 50% of the © Jones & Bartlett Learning, LLC © ofJones BartlettforLearning, LLC lic health purposes across all state and local agencies with 100,000 full-time equivalent (FTE) employees of state health NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION health roles, including substance abuse, mental health, and endepartments perform their duties from regional, district, or vironmental protection agencies. This limitation is especially local sites. apparent for environmental health and protection roles. As illustrated in Figure 4–2, state and local governments The organizational placement and specific responsibilispent nearly $300 billion on health-related purposes in 2008. © Jones & Bartlett Learning, LLC © Jones Bartlett Learning, LLCthe size of their ties of state& health agencies largely determine Health expenditures have comprised 13–15% of state and local NOT FOR SALE OR DISTRIBUTION FOR SALE OR budgets and workforce. JustDISTRIBUTION over 50% of the state health agengovernment expenditures since 1990 (Figure 4–3). Before the NOT

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FIGURE 4–7 States with responsibilities in emerging areas of public health practice, United States, 2001.

© Jones & Bartlett Learning, LLC 28% NOT FOR SALE OR DISTRIBUTION

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State Title XXI children’s health insurance

Institutional review board

45%

Breast and cervical cancer treatment

45% 55%

Radon control

© Jones & Bartlett Learning, LLC Toxicology NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC NOT FOR57% SALE OR DISTRIBUTION 62%

Quality or performance improvement

64%

Emergency medical services Violence prevention

© Jones & Bartlett Learning, LLC Perinatal epidemiology NOT FOR SALE OR DISTRIBUTION

68% © Jones & Bartlett Learning, LLC 77% NOT FOR SALE OR DISTRIBUTION

Disaster preparedness

77%

Environmental epidemiology

79%

Cancer epidemiology

83%

© Jones & Bartlett Learning, LLC Tobacco control and prevention NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC 83% SALE OR DISTRIBUTION NOT FOR 85%

Chronic disease epidemiology Breast and cervical cancer screening

87%

Injury control epidemiology

87%

© Jones & Bartlett Learning, LLC Vaccines for children NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC 87% NOT FOR SALE OR DISTRIBUTION

Bioterrorism 0%

89% 20%

40%

60%

80%

100%

© Jones & Bartlett Learning, JonesN.&Structure Bartlett Learning, LLC Source: Data LLC from Beitsch LM, Brooks RG, Grigg M,©Menachemi and functions of state public health agencies. Am J Public Health. 2006;96:167–172. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

cies have 1,500 or fewer employees; these agencies have budgcal year 2003 indicate that states spent about $10 billion from Jones &This Bartlett Learning, © Jones & heath Bartlett Learning, LLC ets approximating © $250 million. group includes manyLLCstate sources on population-based public activities. This FORexpenditures SALE OR NOT SALE ORfor DISTRIBUTION freestanding agencies thatFOR have responsibility traditional represents about 5.4% of allNOT state health andDISTRIBUTION 1.7% public health services but not for Medicaid, mental health, of the total state budget. In addition, states expended another substance abuse, and environmental regulation. As these other $9 billion of federal funding to support population-based servresponsibilities are added, the budgets and workforce of state ices. Breakdowns for different types of population-based pubhealth agencies increase substantially. Nine state health agenlic health activities&are providedLearning, in Figure 4–8. A higher © Jones & Bartlett Learning, LLC © Jones Bartlett LLC cies haveFOR more than 4,500 employees and average expenditures percentage of state funds supported protection, NOT SALE OR DISTRIBUTION NOT FOR SALE OR environmental DISTRIBUTION of almost $6 billion. injury prevention, and infrastructure activities, while a higher In order to identify state government expenditures for pubpercentage of federal funds went for disaster preparedness and lic health activities, it is necessary to examine the budgets of chronic disease prevention activities. State and federal funds multiple state agencies. The official state health agency is not the equally supported prevention of epidemics and spread of dis© Jones & Bartlett LLC supporting population-based © Jonesease. & Bartlett Learning, LLC include grants and only unit Learning, of state government State health agency expenditures NOT FOR SALE NOT SALE OR DISTRIBUTION publicOR healthDISTRIBUTION activities. Data on state health expenditures for fis- FOR contracts to LHDs, although the current level of these inter-

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FIGURE 4–8 State population-based public health expenditures for public health functions, United States, 2002–2003.

• Occupational Safety and Health Act

States, however, have re© Jones & Bartlett Learning, LLC sponded in no consistent manner State NOT FOR SALE OR DISTRIBUTION 18 in assigning implementation of fedFederal 16 eral statutes among various state 10.0 14 agencies. The focus of federal statutes on specific environmental 12 © Jones & Bartlett Learning, LLC © Jones & Bartlett LLC media (water, air,Learning, waste) has fos10 tered the assignment of environNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 8 mental responsibilities to state 6 agencies other than official state 2.2 9.2 4 health agencies, as demonstrated 3.9 0.2 2 3.7 in Table 4–3. The implications of 1.0 0.7 LLC 0.3 2.1 1.6 © Jones & Bartlett Learning, © 2.0 Jones 0.5 & Bartlett Learning, LLC 0.9 0 this diversification are important NOT FOR SALE OR Environmental DISTRIBUTION NOT FOR SALE OR for DISTRIBUTION Disease Injury Chronic Disaster Infrastructure Population public health agencies. State Control Hazards Prevention Disease Prep/Response Health Total health agencies are becoming less involved in environmental health Source: Data from Milbank Memorial Fund, National Association of State Budget Officers, and the Reforming States Group. 2002–2003 State Health Expenditures Report, June 2005. www.milbank.org/reprograms; only a handful of states ports/05NSBO/index.html. Accessed June 15, 2010. utilize their state health agency as Learning, LLC © Jones & Bartlett Learning, LLC © Jones & Bartlett the state’s lead agency environNOT FOR for SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION mental concerns. This role has governmental transfers is not known. In 1991, an estimated $2 shifted to state environmental agencies, although many other billion was transferred from states to LHDs.12 state agencies are also involved. Still, the primary strategy has At the federal level, more than a dozen federal departshifted from a health-oriented approach to a regulatory ap© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ments, agencies, and commissions (Transportation, Labor, proach. Despite their diminished role in environmental conNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Health and Human Services, Commerce, Energy, Defense, cerns, state health agencies continue to address a very diverse EPA, Homeland Security, Interior, Consumer Product Safety set of environmental health issues and maintain epidemioCommission, Agriculture, Nuclear Regulatory Commission, logic and quantitative risk assessment capabilities not availand Housing and Urban Development) have environmental able in other state agencies. Linking this important expertise to health State and local governments workings other stateLearning, agencies is a particularly challeng© Jones & roles. Bartlett Learning, LLC have largely repli- ©the Jones & ofBartlett LLC cated this web of environmental responsibility, creating a ing task, and there are other implications of this scenario, as NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION complex system often poorly understood by the private secwell. tor and general public. Federal statutes have driven the The shift toward regulatory strategies is clearly reflected in organization of state responsibilities. Key federal environresource allocation at the state level. In the mid-1990s, about mental statutes include $6 billion was spent on environmental health and regulation © Jones & Bartlett Learning, LLCwith only about $1 billion©ofJones Bartlett by states, that total&for environ- Learning, LLC NOT FOR regulation) SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Clean Air Act mental health (as opposed to environmental 13 • Clean Water Act activities. Public health considerations often take a back seat • Comprehensive Environmental Response, Competition, to regulatory concerns when budget decisions are made. In and Liability Act and Superfund Amendments and addition, the fact that many environmental health specialists Reauthorization Act are working in nonhealth agencies poses special problemsLLC for © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, • Federal Insecticide, Fungicide, Rodenticide Act both their training and FOR their practice NOT FOR SALE ORand DISTRIBUTION NOT SALEperformance. OR DISTRIBUTION • Resource Conservation and Recovery Act The wide variation in organization and structure of state • Safe Drinking Water Act health responsibilities suggests that there is no standard or • Toxic Substance Control Act consistent pattern to public health practice among the various • Food, Drug, and Cosmetic Act states. An examination of enabling statutes and state public © Jones & Bartlett LLCAct ©agency Jones & Bartlett Learning, LLCsupport for this • Federal MineLearning, Safety and Health mission statements provides further

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$ in Billions

20

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TABLE 4–3 Number and Type of State Agencies Responsible for Implementation of Federal Environmental Statutes Statute © Jones

& BartlettAgriculture Learning, LLCEnvironment 0 41 NOT FOR SALE OR DISTRIBUTION

Clean Air Act Clean Water Act 1 CERCLA (Superfund) Act 3 Federal Insecticide, Fungicide, 0 and Rodenticide Act Resource Conservation and 0 © Jones & Bartlett Learning, LLC Recovery Act NOT FOR SALE Safe Drinking Water ActOR DISTRIBUTION0 Toxic Substance Control Act 37 Food, Drug, and Cosmetic Act 1 Federal Mine Safety and Health Act 0 Occupational Safety and Health Act 15

Health Labor © Jones & Bartlett

Total Learning, LLC 10NOT FOR SALE 1 52 OR DISTRIBUTION

41 38 41

11 25 11

1 1 2

54 67 54

36

33

3

72

4 1 0 1

5 15 0 13

0 39 12 0

46 56 12 29

© Jones & Bartlett Learning, LLC OR DISTRIBUTION 12 NOT FOR SALE 23 3 38

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Source: From Health Resources and Services Administration. Environmental Web: Impact of Federal Statutes on State Environmental Health and Protection— NOT FOR SALE ORStructure DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Services, and Funding. Rockville, MD: HRSA; 1995.

In sum, state health agencies face many challengesLearning, related conclusion. Only 11©ofJones 43 state agency missionLearning, statements ad-LLC & Bartlett © Jones & Bartlett LLC to the fragmentation of public health roles and responsibilities dress the majorityNOT of the FOR concepts related to public health NOT FOR SALE OR DISTRIBUTION SALE OR DISTRIBUTION among various state agencies. Central to these are two related purpose and mission in the Public Health in America docu14,15 ment. When state public health enabling statutes are exchallenges: how to coordinate public health’s core functions amined for references to the essential public health services and essential services effectively and how to leverage changes (also found in the Public Health in America document), the within the health system to instill greater emphasis on clinical © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC majority of the essential public health services can be identiprevention and population-based services. As the various chapNOT FOR SALE OR DISTRIBUTION NOT SALE OR DISTRIBUTION fied in only one fifth of the states. The most frequently identers of this textFOR suggest, these are related aims. tified essential public health services reflect traditional public Local Health Departments health activities, such as enforcement of laws, monitoring of health status, diagnosing and investigating health hazards, In the overall structuring of governmental public health reand informing and educating are whereLLC the “rubber meets the road.” © Jones & Bartlett Learning, LLCthe public. The essential public © Jonessponsibilities, & BartlettLHDs Learning, health services least frequently referenced in these enabling These agencies are established to carry out the critical public NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION statutes reflect more modern concepts of public health prachealth responsibilities embodied in state laws and local orditice, including mobilizing community partnerships, evaluatnances and to meet other needs and expectations of their coming the effects of health services, and research for innovative munities. Although some cities had local public health boards solutions. Only three states had both enabling statutes and and agencies prior to 1900, the first county health department Jones & Bartlett Learning, © Jones Bartlett LLC state health agency © mission statements highly congruent withLLCwas not established until 1911. At that&time, Yakima Learning, County, NOT FOR SALE NOT inFOR SALEHealth OR DISTRIBUTION the concepts advanced the Public in America Washington, created a permanent county healthOR unit,DISTRIBUTION based 14 document. on the success of a county sanitation campaign to control a State-based public health systems blend the roles of the serious typhoid epidemic. The Rockefeller Sanitary state health agency and the LHDs in that state. In more than Commission, through its support for county hookworm erad40 states, all areas of the state are served by an LHD. Where ication© efforts, also& stimulated developmentLLC of county© Jones & Bartlett Learning, LLC Jones BartletttheLearning, there no LHD to provide health services, the state based LHDs. number of LHDs grew rapidly during the NOTis FOR SALE OR public DISTRIBUTION NOT The FOR SALE OR DISTRIBUTION health agency generally provides basic public health coverage. 20th century, although in recent decades, expansion has been Increasingly, states are using regional or district structures to tempered by closures and consolidations. provide oversight and support for LHDs. In more than two LHDs should not be considered separately from the state thirds of states, local boards of health also provide direction network in which they operate. It is important to remember © Jones & Bartlett Learning, LLChealth activities. © Jonesthat & states, Bartlett Learning, LLC and executive branches, and oversight of local public through their state legislative

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establish the types and powers of local governmental units that responsibilities delegated or assigned to them. In contrast, cities can exist in that state. In this arrangement, the state and its local are generally not established as agents of the state. Instead, subunits, however defined, share responsibilities for health and they have considerable discretion through home rule powers other state functions. How health duties are shared in any given to take on functions that are not prohibited to them by state © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC state depends on a complex set of factors that include state and law. Cities can choose to have a health department or to rely on NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION local statutes, history, need, and expectations. the state or their county for public health services. City health Local health agencies relate to their state public health sysdepartments often have a wider array of programs and services 4 tems in one of three general patterns. In most states, LHDs are because of this autonomy. As described previously, the earliest formed and managed by local government, reporting directly public health agencies developed in large urban centers, prior to some office of local& government, as a localLLC Board of to the development of either & state health agencies or county© Jones Bartlett such Learning, © Jones Bartlett Learning, LLC Health, county commission, or city or county executive officer. based LHDs. This status also contributes to their sense of auNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION In this decentralized arrangement, LHDs often have considertonomy. These considerations, as well as the increased demands able autonomy although they may be required to carry out and expectations to meet the needs of those who lack adequate specific state public health statutes. Also, there are some states health insurance, have made many city-based, especially big that share oversight of LHDs with local government through city-based, LHDs qualitatively different from other LHDs. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC the power to appoint local health officers or to approve an anBoth cities and counties have resource and political bases. NOT FOR SALEInOR DISTRIBUTION FOR SALE OR DISTRIBUTION nual budget. some states with decentralized LHDs, some NOT Both rely heavily on property and sales taxes to finance health areas of the state lack coverage because the local government and other services, and both are struggling with the limitations chooses not to form a local health agency and the state must of these funding sources. Political resistance to increasing taxes provide services in those uncovered areas. This mixed arrangeis the major limitation for both. Relatively few counties and ment occurs in about 20% of states. & Another 30% Learning, of the citiesLLC have imposed income taxes, the form of taxation relied Learning, LLC © the Jones Bartlett © Jones & Bartlett states use a more centralizedNOT approach, in SALE which local upon by federal and state governments. both generNOTHowever, FOR SALE OR DISTRIBUTION FOR ORhealth DISTRIBUTION agencies are directly operated by the state or there are no LHDs ally have strong political bases, although cities are generally and the state provides all local health services. Classifying these more likely than counties to be at odds with state government arrangements as decentralized, centralized, or mixed is useful on key issues. from the perspective of the state-local public health system. Counties play a critical role in the public sector, the extent © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC From the perspective of the LHD and the population it serves, and importance of which is often overlooked. Three fourths of NOT FOR SALE OR DISTRIBUTION NOT FOR OR DISTRIBUTION all LHDs are organized at the SALE county level, serving a single however, the LHD is either a unit of local government or a county, a city-county, or several counties. As a result, counties unit of state government. provide a substantial portion of the community prevention LHDs are established by governmental units, including and clinical preventive services offered in the United States. counties, cities, towns, townships, and special districts, by one of care for about 40 million persons who access two general methods. The legislative body may create an LHD ©Counties © Jones & Bartlett Learning, LLC Jonesprovide & Bartlett Learning, LLC LHDs and other facilities; they spend more than $30 billion of through enactment of a local ordinance or a resolution, or the NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION their local tax revenues on health and hospital services annucitizens of the jurisdiction may create a local board and agency ally through some 4,500 sites that include hospitals, nursing through a referendum. Both patterns are common. Resolution homes, clinics, health departments, and mental health facilities. health agencies are often funded from the general funds of the Counties play an explicit role in treatment, are legally responjurisdiction, whereas referendum health agencies often have a © Jones Bartlettand Learning, ©30Jones & Bartlett sibleLLC for indigent health care in over states, and pay a por- Learning, LLC specific tax levy available to them. There are&advantages disNOTinFOR NOT FOR health SALEagencies OR DISTRIBUTION tion of the nonfederal share of Medicaid about SALE 20 states.OR In DISTRIBUTION advantages to either approach. Resolution are addition, counties purchase health care for more than 2 milsimpler to establish and may develop close working relationlion employees.16 ships with the local legislative bodies that create them. Referendum agencies reflect the support of the local electorate The National Association of County and City Health and may have access to specific tax levies that preclude the need Officials (NACCHO) tracks public health activities of LHDs; © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 17 Data to compete with other local government funding sources. the most recent survey of LHDs took place in 2008. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Counties represent the most common form of subdividprovided in this chapter are derived from this 2008 survey, as ing states. In general, counties are geopolitical subunits of states well as from several earlier surveys.16–19 that carry out various state responsibilities, such as law enOne limitation of information on LHDs is that there is forcement (sheriffs and state’s attorneys) and public health. neither a clear nor a functional definition of what constitutes © Jones & Bartlett Learning, LLC & most Bartlett LLC Counties largely function as agents of the state and carry out ©anJones LHD. The widelyLearning, used definitions call for an admin-

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istrative and service unit of local government, concerned with Local boards of health are associated with most LHDs; in health, employing at least one full-time person, and carrying 2008, 80% of LHDs reported working with a local board of responsibility for health of a jurisdiction smaller than the state. health. There are an estimated 3,200 local boards of health; By this definition, more than 3,200 local health agencies opabout 85% reported an affiliation with an LHD. However, 15% © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC erate in 3,042 U.S. counties.18 The number of LHDs varies exist independently of any LHD; this pattern is most common NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION widely from state to state; Rhode Island has none, whereas in Massachusetts, Pennsylvania, New Hampshire, Iowa, and neighboring Connecticut and Massachusetts report more than New Jersey. The pattern for size of population, type of juris100 LHDs. diction, and budget mirrors that for LHDs. Virtually all local Nearly 60% of LHDs are single-county health agencies, boards of health establish local health policies, fees, ordinances, and over 80%&operate out of a county base (single county, and regulations. Most recommend and/or approve © Jones Bartlett Learning, LLC © Jones &also Bartlett Learning, LLC budg17 Other LHDs function at the multicounty, or city-county). ets, establish community health priorities, and hire the direcNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION city, town, or township levels; some state-operated units also tor of the local health agency. Although four fifths of LHDs serve local jurisdictions. Although the precise number is unrelate to a board of health, only 56% report only to that board certain, it appears that the total number of LHDs has been inrather than some other office of local government. In recent creasing, from about 1,300 in 1947 to about 2,000 in the decades, the roles of local boards of health have shifted away © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC mid-1970s to somewhere over 3,000 today. from policy making to more advisory duties as local governNOT FOR SALESeveral OR DISTRIBUTION SALE OR DISTRIBUTION reports going back more than 50 years haveNOT pro- FOR ments have become more directly involved with oversight of posed extensive consolidation of small LHDs because of their LHDs. perceived lack of efficiency and coordination of services, inSimilar to the situation with state health agencies, data on consistent administration of public health laws, and inability LHD expenditures lack currency and completeness. Annual of small LHDs to raise adequate&resources to Learning, carry out theirLLCLHD expenditures in 2008 from than $10,000 to © Jones Bartlett ©ranged Jones & less Bartlett Learning, LLC prime functions effectively. Consolidations at theDISTRIBUTION county level over $1 billion. One half ofNOT LHDsFOR had budgets of $1 million or SALE OR DISTRIBUTION NOT FOR SALE OR would appear to be the most rational approach, but only limless, and 29% had budgets over $5 million. Total expenditures ited progress has been achieved in recent decades. increase with size of population. LHDs located in metropoliMost LHDs are relatively small organizations; as illustan areas had substantially higher expenditures than their nontrated in Figure 4–9, 64% serve populations of 50,000 or metropolitan area counterparts. The median per capita LHD © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC fewer while 31% of LHDs serve NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION populations of 50,000–499,999. FIGURE 4–9 Small, medium, and large LHDs; percentage of all LHDs and perOnly 5% of LHDs serve populacentage of population served, United States, 2008. tions of 500,000 or more residents. 17 Nearly 90% of the U.S. 100% population is served by LLC an LHD in © Jones & Bartlett Learning, © Jones & Bartlett Learning, LLC Percentage of all LHDs 90% the medium and large population Percentage U.S. Population NOT FOR SALE OR DISTRIBUTION NOT ofFOR SALEServed OR DISTRIBUTION categories. 80% Some states set qualifications 70% 64% for local health officers or require 60% medical supervision when the ad46% 50%Learning, LLC © Jones & Bartlett © Jones & Bartlett Learning, LLC ministrator is not a physician. About 41% 40% DISTRIBUTION NOT FOR SALE OR DISTRIBUTION FOR SALE OR four fifths of LHDsNOT employ a full31% 30% time health officer. Health officers have a mean tenure of about 8 years 20% 12% and a median tenure of about 9 10% 5% years. Approximately 15% are physi© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 0% cians. oneOR fourth of Small (

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