Module 4

Law, Government,and Public Health

Module 4 Will Help You To:

• identify strategies used by governments to influence the health status of their citizens

• describe how various forms of law contribute to government's ability to influence health

• describe the basic administrative law processes carried out by public health agencies

• identify the various federal health agencies and describing their general purpose and major activities

• identify different approaches to organizing health responsibilities within state government

• describe common features of local health departments in the United States

• discuss implications of different approaches among states to carrying out public health's roles

American Governmentand Public Health

• “All politics is local” but is all public health local as well?

• Federalism and Public Health– “Health” hard to find in US Constitution– Relative roles of national, state and local

governments in health matters shift over time– Social values shift over time as well

Public Health Law

• Different forms for law– Constitutionally based law– Legislatively based law– Administrative law– Judicially based law

• Purposes for public health laws– Protect and promote health (police and

general welfare powers)– Ensure rights of individuals

Administrative Law

• Separation of powers (legislative, executive, judicial) not apparent in administrative law

• Reliance on experts and professionals

• Extensive impact on daily life

Governmental Public Health

• Major levels– National: federal health agencies such as

DHHS and its components– Tribal: Indian Health Service and others– State: state health agencies such as health

departments and human service agencies– Local: local public health agencies, often

called local health departments

Federal Health Agencies

Fiscal Year 2007 U.S. Public Health Service Agency Budget Authority.

Source: Fiscal Year 2007 Budget, USDHHS, 2006.

$1.5

$6.2

$3.3

$5.8

$28.6

$3.1

$0.3

$0 $5 $10 $15 $20 $25 $30 $35

FDA

HRSA

IndHS

CDC

NIH

SAMHSA

AHRQ

Pu

blic

He

alt

h S

erv

ice

Ag

en

cie

s

$ in Billions

State Health Agencies

• Health roles and duties often scattered among dozens of agencies

• Many different configurations for state health agency (free-standing, unit or larger health and human services agency, etc.)

• Various duties depending on above.

States with Responsibilities in Emerging Areas of Public Health Practice: United States, 2001.

Source: Beitsch et al. AJPH 2006;96:167-172.

89%

87%

87%

87%

85%

83%

83%

79%

77%

77%

68%

64%

62%

57%

55%

45%

45%

28%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Bioterrorism

Vaccine for Children

Injury control epidemiology

Breast and cervical cancer screening

Chronic disease epidemiology

Tobacco control and prevention

Cancer epidemiology

Environmental epidemiology

Disaster preparedness

Perinatal epidemiology

Violence prevention

Emergency medical services

Qaulity or performance improvement

Toxicology

Radon control

Breast and cervical cancer treatment

Institutional review board

State Title XXI Children's Health Insurance

Selected Organizational Responsibilities of State Health Agencies, 2002.

Source: ASTHO 2002 Salary Survey of State and Territorial Health Officials.

98%

94%

94%

90%

82%

78%

76%

53%

37%

35%

29%

25%

20%

16%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

WIC

Vital statistics

Tobacco prevention

public health laboratories

Food safety

Health facility regulation

Environmental health

Drinking water regulation

Drug/Alcohol abuse prevention

Health professional licensing

Medical examiner

Environmental regulation

Mental health

Medicaid

Local Public Health Organizations

• Where the rubber meets the road

• Often relate to 10 or more state and federal agencies for funding and direction

• 2 basic arrangements– Decentralized: relate primarily to local

government although may also report to state health agency

– Centralized: a unit of the state health agency

Small, Medium and Large Local Public Health Agencies (LPHAs): Percentage of All LPHAs and Percentage of Population Served,

United States, 2005.

Source: NACCHO, 2006. 62%

10%

32%

37%

6%

54%

0%

10%

20%

30%

40%

50%

60%

70%

Small (<50,000) Medium (50,000-499,999) Large (500,000+)

Size of Population Served by LPHA

% of All LPHAs

% Population Served

Median FTEs in Selected Occupational Categories Employed by LHDs.Source: NACCHO, 2006

Population Served

<25k 25-50k 50-100k 100-500k 500k+

All LHD Staff 6 16 33 88 325

Manager 1 1 1 5 15

Nurse 2 5 10 20 69

Physician 0 0 0 1 3

Env Health Specialist 1 2 3 9 24

Other Env Health Scientist 0 0 0 1 5

Epidemiologist 0 0 0 1 2

Health Educator 0 0 0 2 6

Nutritionist 0 0 1 3 8

Info Sys Spec 0 0 1 1 3

Pub Info Spec 0 0 0 0 1

Emergency Prep Coord 0 0 0 1 1

Clerical 2 4 8 23 72

Intergovernmental Relationships

• Prior to 1915, federal government had minimal health role and little financial power; states had authority but local governments were where the action was

• After 1915, federal tax resources and social shifts pushed federal government to become more active; states retained primary authority and local governments were unable to keep up with local needs and expectations

Federal public health spendingas percent of adjusted total public health spending

US, 1960-2000

71.57%

63.95%

41.98%

28.63%

29.77%

28.83%

29.47%

62.94%

53.13%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1960 1965 1970 1975 1980 1985 1990 1995 2000

Adjusted total public health spending (in millions)from federal and state/local sources

US, 1960-2000

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

$16,000

$18,000

$20,000

1960 1965 1970 1975 1980 1985 1990 1995 2000

Adjusted total public health spending

Adjusted state/local public health spending

Federal public health spending

Implications at Century’s End

• Expectations rising

• Federal role diminished

• Health policy investment opportunities– Tobacco settlement– BT preparedness

• Emergency public health preparedness now both a national security as well as personal safety priority

Discussion

• All learners should be making arrangements to attend a meeting of an official board of health (these meetings are open to the public). This may require some advanced planning since many boards of health meet only once a month. If you are unsure of what a board of health is, visit the National Association of Local Boards of Health (NALBOH) web site, especially the article "About Local Boards of Health." Another useful resource is the Illinois Department of Public Health site on local health departments in Illinois (or similar information for your state).

Discussion

• Select a local public health agency from a state other than Illinois (also, it must not relate to the Board of Health whose meeting you will be attending!) and identify the jurisdiction it serves and whether or not it relates to a local board of health. Also include information as to how this local public health agency was established (resolution or referendum), who it reports to, and how it relates to the state health agency (for example: Is it a unit of the state agency or an independent entity?  Is it certified or accredited by the state?).