Transforming the Public Health System: What Are We Learning?
While there has been an enormous amount of attention paid to the transformation of the United States Health Care delivery system under the Affordable Care Act (ACA), little has been said about the many opportunities in the ACA for population health systems improvement that will present as the result of moving to an environment where a substantial portion of the population has a health insurance card.
The governmental public health system has three core functions as defined in a 1988 report by the Institute of Medicine (IOM). These functions are to assess the health of the community, lead and promote evidence-based policies that are in the public’s interest, and assure the availability of community and personal health services that are viewed by their constituents as appropriate and necessary. [1] These public health functions will not change with health reform, but many of their component activities will as the health system is transformed.
During the Clinton health reform debate in 1994, it became apparent that a more detailed definition of governmental public health services was needed. The Core Public Health Functions Steering Committee was formed and it delineated ten essential services to be provided or assured by all health departments. All of these ten services will need to adjust in an evolving health system.
These services include:
- Monitor health status to identify and solve community health problems;
- Diagnose and investigate health problems and health hazards in the community;
- Inform, educate, and empower people about health issues;
- Mobilize community partnerships to identify and solve health problems;
- Develop policies and plans that support individual and community health efforts;
- Enforce laws and regulations that protect health and ensure safety;
- Link people to needed personal health services and assure the provision of health care when otherwise unavailable;
- Assure a competent public and personal health care workforce;
- Evaluate effectiveness, accessibility, and quality of personal and population-based health services and;
- Research for new insights and innovative solutions to health problems. [2]
Health system reform will impact these essential services in three overarching ways. First, the expansion of health insurance coverage will result in adjustments to the clinical services currently provided by governmental public health agencies. In some cases, like routine childhood vaccinations, these adjustments may transfer to the private sector. Other, more specialized services, like those for people with tuberculosis or sexually transmissible diseases may remain with public health as the primary provider. In this situation, the public health agency could expand to provide these targeted services to a range of private health systems where the public health agency may provide the service more efficiently. How and what the changes are remains to be seen, but planning for this transformation must occur now in order to maximize the opportunities the ACA presents.
The second impact on these essential services will be the opportunity to integrate population health principles into the many new delivery system models (Accountable Care Organizations, integrated health systems, and medical homes), as well as to work to optimize the enhanced requirement for hospitals to better define and utilize their community benefit efforts. Here, public health practitioners and the agencies they represent can share their expertise on assessing the health of populations, crafting and implementing community- and broadbased solutions, and evaluating the outcomes of these solutions. We need to explore more fully this value added to the new health care models.
The third impact of health care reform is the opportunity to offer many traditional public health enabling or data services to the broader public. Public health agencies provide a plethora of programs and services that enhance access to and quality of clinical care for underserved populations that should be made available to the broader population. These include such programs as home visiting and other maternal child health programs, health care linkage and support services and specialized behavioral health services. These are in addition to the many population-based prevention, protection, and regulatory programs designed to ensure our food is safe to eat, our air is safe to breathe, and our water is safe to drink.
Like the health care delivery system, public health is at a crossroads. There is a lot to learn as we make this transformation to achieve better health and better value for our health investment. A transformed public health system is an essential element of that change. We should embrace it.
References
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Institute of Medicine. 1988. The Future of Public Health. Washington, DC: The National Academies Press. https://doi.org/10.17226/1091.
- National Public Health Performance Standards Program. 2010. 10 Essential Public Health Services. Available at: https://www.cdc.gov/publichealthgateway/nphps/index.html (accessed January 28, 2020).
