What would the national public health system look like?

At the start of the pandemic, it was easy to be sure that the American health care system could meet the challenge. However, this optimism has long since disappeared due to more than 1 million deaths and ongoing infections, which led to 100,000 new cases almost every day in June.

“The national response to the COVID-19 pandemic has revealed deep weaknesses and disorganizations in the US public health system,” said David Blumenthal, president of the Commonwealth Fund, a philanthropic organization working on health and social justice.

The British Community Fund has convened a group of leading health experts tasked with rethinking the national health system. Their recommendations have just come out.


Available in four main flavors. One is a call on the federal government to do a better job of coordinating its own capabilities and resources. Another is for Congress to provide a steady stream of funding for state, local and tribal health departments – $ 8 billion a year. They call for hospital systems and health care providers to integrate more closely with health services. And they note that public health officials themselves need to do a better job of communicating with the public and restoring its trust.

“The COVID-19 crisis has highlighted many of the long-standing gaps in public health and its ability to respond to both day-to-day worries and crises,” said Margaret Hamburg, a former food and medicine commissioner who is leading the effort. We need more than ad hoc strategies.

There is no guarantee that Congress – which no longer seems interested in securing funding for the current pandemic, let alone worrying about future reforms – will respond to the recommendations. But it is clear that no one would design the system as we have it now, which makes serious efforts to rethink public health valuable.

Public health is as decentralized as any other function of government – and more fragmented than most. The federal government has never had a public health agency with broad powers to respond to emergencies and current challenges. The Federal Centers for Disease Control and Prevention (CDC) usually plays a leading role, outlining strategies that are then implemented by states and localities, with Congress coming later to replenish funding. This model disintegrated during the coronavirus pandemic.

Instead, the nation has seen an answer that is very different from place to place. Both the disease and its responses are polarizing, with not only different but often opposing strategies being pursued in Republican and Democrat-led jurisdictions. “The challenges of gaining trust are particularly great and it is difficult to do so in the sea of ​​misinformation we are in,” said Joshua Scharfstein, vice dean of the Johns Hopkins Bloomberg School of Public Health, who worked for the Foundation. of the British Commonwealth. report.

It’s not really a system

It is common to refer to the American “health care system”, but in reality the vast and scattered networks of hospitals, public health centers, doctors’ offices and emergency clinics are in almost every kind of communication with each other. As for the government, there is an alphabetical set of agencies at the federal level that do not coordinate well with each other, let alone nearly 3,000 state and local health departments across the country.

“In the absence of an official or service to lead the public health effort, the HHS (Federal Ministry of Health and Human Services) has difficulty coordinating the work of large and powerful agencies that are essential to public health, both within the the department, as well as elsewhere in the federal government and with non-federal partners, ”the Commonwealth Fund report concluded.

Instead of setting up a new public health department, the report calls for the creation of a deputy secretary of public health at the HHS. The idea is not to create a new layer of bureaucracy, Hamburg says, but rather to put someone in charge to make sure agencies know who is responsible for what and to ensure that budgets are in line with priorities. “The creation of a deputy secretary brings HHS in line with other departments,” she said. “We don’t have to wait until we get approval from Congress. There are things the HHS secretary can do right now.

Among other changes, the report recommends that the White House convene a permanent council to coordinate federal public health efforts with states, localities, tribes and territories. As noted earlier, the report also recommends increasing Congressional funding to support these governments.

State and local health officials have long complained that they are not getting enough help from Washington – and that this is the wrong kind of help. The money is pouring into health services after emergencies such as Ebola or the terrorist attacks of 2001. But almost everything is for specific purposes and cannot be used to address other current challenges.

This includes capacity building in areas such as data infrastructure. Difficulties in accessing and using basic information, even for cut and dried figures such as the number of deaths, have been a sore spot – or rather a blind spot – throughout the pandemic.

“Our systems are archaic,” said Julie Gerberding, a former CDC director who worked on the Commonwealth Fund report. “Some jurisdictions still fax back and forth.”

Compliance with minimum standards

To receive increased federal funding, state and local governments will need to demonstrate their ability to perform a range of core functions. The Commonwealth Fund report calls on the administration to rethink the accreditation system for health departments to ensure that they can all function at a certain level.

“The place where you live should not determine how well your health department protects you from public health threats,” the report said. “This is not the case today and no basic standard has been set for public health capabilities.”

Several small health departments hire an epidemiologist; many who have one who works only part-time. “It’s hard to take care of public health if you don’t have someone who knows how to collect that data,” said David Lakey, a former Texas health commissioner.

The United States spends much more on health care — treating individual patients for illness or injury — than on public health, which is about trying to change the conditions that lead to illness or injury. It is important, Lekey says, for health care providers to share data with health departments so they can identify challenges to infectious or chronic diseases.

It’s time for the Medicare and Medicaid Services (CMS) centers to demand more information sharing from private providers, says Scharfstein, a professor at John Hopkins. The more information is shared, the better prepared the health departments will be when there are emergencies.

“Let’s be honest: CMS has a lot of leverage over the healthcare system,” he said. “It’s important for the federal government to use part of that leverage to set some standards and core expectations.”

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