Microsoft Word - Volume 14.doc Commonwealth: A Journal of Political Science  Volume 14, Number 1  December 2008 Special Policy Issue on Public Health  2008 PPSA/LORL, PA House of Reps. ISSN 0890-2410 Public Health in Pennsylvania: Where Do We Go From Here? Margaret A. Potter, JD, MS University of Pittsburgh Graduate School of Public Health What is Public Health and Why Does It Matter? “Health care” and “public health” are different kinds of activities. Health care is about the relief and cure of illnesses and support for disabilities. Public health is about health protection: preventing illnesses and promoting vigor and longevity. Health care involves diagnosis and treatment services for individual patients. Public health involves assessment of population-wide health trends (including screenings and preventive care for individuals), development of policies and programs to optimize healthy conditions, and assurance of access to basic services (Institute of Medicine 1988 and 2003). Health care is largely a private- sector enterprise, with its organization and financing carried out by non- profits and businesses through physicians’ offices and clinics, hospitals, pharmacies, rehabilitation centers, and nursing facilities. Public health, though sharing some part with the private sector, depends primarily on public oversight and accountability – roles that must be grounded in the police powers of sovereign states (Institute of Medicine 1988; Gostin 2000). Pennsylvania is health-care rich and public-health poor. Pennsylvania has 3.23 hospital beds for every 1,000 residents, well above the national average of 2.75 beds per 1,000, and well above the number in other populous states such as California (2.00 per 1,000), Texas (2.58 per 1,000), and Florida (2.87 per 1,000) (Federal Reserve Bank of Minneapolis 2004). Pennsylvania also ranks high in the number of physicians per capita with 0.332 per 100 residents, and ranking in the top 10 states along with Washington, DC, Massachusetts, New York, and Maryland (Statemaster.com 2008). Pennsylvania spends annually more per capita on health care than all but six other U.S. states (Statemaster.com 2008). But this Commonwealth ranks last among states 2 PUBLIC HEALTH IN PENNSYLVANIA: WHERE DO WE GO FROM HERE? in the number of public health workers per capita: 37 per 100,000 compared to a national average of 158 per 100,000 (Gebbie et al. 2000). Only six of Pennsylvania’s 67 counties (Allegheny, Bucks, Chester, Erie, Montgomery, and Philadelphia) and an additional four cities (Allentown, Bethlehem, Wilkes-Barre, and York) have full-service local health departments. That leaves about half of the state’s population dependent upon the state’s Department of Health, which employs fewer than one- third of the state’s public health workforce. These statistics lead to some difficult questions. Does the Commonwealth’s de-emphasis on health protection depress the real quality of life for citizens? If so, how much would greater health protection cost, and who would pay for it? If health protection depends on vigorous oversight and accountability, how should government and the private-sector share those duties? What Defines a Well-Functioning Public Health System? A public health system is "the organizations and individuals who collectively share the benefits, burdens, and responsibilities for the health of a defined population or community" (Halverson 2002). It includes many entities besides state and local public health agencies, such as health care providers, community-based organizations, emergency management, and schools – to name just a few. Health protection depends on the strengths of these entities acting in coordination. The quality and effectiveness of a public health system depend on its laws (Gostin 2000) as well as its financing and organizational structures (Mays et al. 2006). If the laws are unclear, the financing inadequate, and the organizations fragmented, then threats to health are likely to be unchecked. Local-level agencies are the public health system’s hub because they can plan for the characteristic needs of local populations, prioritize resource allocation, and maintain accountability to local authorities (National Association of County and City Health Officials 2007). Effective planning among human service and public safety organizations depends upon local specificity. Private rights and interests, which may be affected by population-level interventions, are best protected by local controls. For example, when quarantines are needed to quench an Margaret A. Potter 3 influenza pandemic, locally knowledgeable officials determine the most effective and least intrusive methods. Without governance and cohesion at the county and municipal levels, public health activities may be uninformed and resources may be misdirected. Local financing is also critical: a recent national study revealed that a relatively high proportion of local financing in a local health agency’s budget correlated with high performance in rendering essential public health services (Mays et al. 2006). Nevertheless, local governments cannot alone sustain the legal, economic, and organizational burden of public health systems. State laws delegate the necessary legal authority, even if local codes and official discretion determine how the laws are implemented. Except for the largest metropolitan areas nationally, local tax bases and local health and human service organizations cannot alone sustain the high levels of professional expertise and technical facilities that determine effectiveness in health protection services. Thus, intergovernmental cooperation, as well as partnerships with private-sector organizations, is critical to well-functioning public health systems. How Well Does the Commonwealth’s Public Health System Perform? Based on this Public Health Symposium issue of Commonwealth, it is fair to say that Pennsylvania’s current public health system performs inadequately. The system itself is legally ambiguous, comparatively under funded, and organizationally fragmented. County governments resist making long-term financial and organizational commitments to public health activities, despite the availability of state per-capita matching grants intended to incentivize such local investment. Public health agencies in Pennsylvania exist at multiple levels of government (state, county, and municipal); and their respective sources of authority are distributed without coordinated oversight and accountability among numerous agencies (Health, Welfare, Agriculture, Insurance, Environmental Protection, and Labor and Industry). In Part I of this Symposium, three papers address some of the critical issues in the Pennsylvania public health system. In a paper titled “Public Health Shortage Areas in Pennsylvania: A Barrier to Health Information,” Dr. Alberto Cardelle and Ms. Deidre Holland compare the 4 PUBLIC HEALTH IN PENNSYLVANIA: WHERE DO WE GO FROM HERE? ease and accuracy of accessing basic public health information in counties and municipalities without local health departments with that in counties and municipalities served by a local health department. Their results show that in locales without local health departments, callers found it more difficult to access health information, were transferred to non-public health entities, and did not speak to a health professional early in the inquiry. Common Pleas Judge John A. Bozza writes in “Crisis in the Making: What’s Wrong with Pennsylvania Public Health Law?” that the system is not only straining to meet everyday health-protection needs but is particularly vulnerable to failure during emergencies and disasters. He warns that “unless key aspects of Pennsylvania law are clarified and/or modified, we risk far from adequate performance from public officials responsible for the public’s health.” Dr. Mariana Chilton and co-authors Chyatte and Gracely describe an evident failure of coordination among human services within the overall public health system in their article, “Evidence that Young Children Are Falling through the Safety Net: Policy Implications of Hunger and Poor Health in Pennsylvania.” This manuscript highlights the disproportionate impact of food insecurity on the health and well-being of children of color in Philadelphia. It offers policy recommendations to decrease the racial-ethnic divide that exists among Philadelphia’s children and protect the right to healthy development for all. Part II of the Symposium includes two papers describing barriers to building health protection capacity in Pennsylvania’s 61 counties that lack a comprehensive public health agency. In “Objecting to Public Health – Stories from Four Pennsylvania Counties,” Professors Dennis Gallagher and Jennifer Kolker report on their recent feasibility studies for establishing countywide health departments in Lancaster, York, Dauphin, and Berks counties. This article presents findings about how local conditions affect the perceptions of both public health needs and the opportunities for enhancing county-based and countywide programs. Their stories help make the case for why public health is best understood within a very local context. In the second of his Symposium articles, “Financial Analysis and Structural Considerations to the Problem of Rural Public Health in Pennsylvania,” Dr. Cardelle describes his study of 10 rural counties and Margaret A. Potter 5 the potential cost of establishing countywide local health departments. This analysis shows that population, geographic area, and the availability of primary care services all drive expenses. He also describes the specific challenges of establishing and maintaining health departments in rural areas and offers policy recommendations to help overcome these barriers. In the Symposium Part III, authors describe several innovations to consider for public health in Pennsylvania. In “A Health Promoting Hospital: A Strategy in the Re-Design of the U.S. Health Care System,” Dr. Matthew Masiello describes a unique Pennsylvania hospital system that took on certain public health responsibilities as a Health Promoting Hospital within the World Health Organization’s international network. He explains the potential benefits of a Health Promoting Hospital initiative within the United States and the use of the World Health Organization’s model program. Dr. Bernard Goldstein writes, in “Credentialing of the Public Health Work Force,” about a new approach to ensuring a highly competent public health work force capable of responding to the public health challenges facing our state and our nation. This article discusses the rationales behind the newly developed proficiency examination leading to a professional credential for public health workers. Dr. Judith Lave and I advance an idea for strengthening the public health system by building upon an existing health care resource. Our article, “Pennsylvania Medical Assistance: Connections Within the Commonwealth’s Public Health System,” describes how that program contributes to the public heath system by assuring access to personal health care services, evaluating the accessibility and quality of personal health services, monitoring health status, and developing policies that support individual health efforts. The article suggests some ways that Medical Assistance could be better connected to the overall public health system. Where Do We Go from Here? These Symposium articles present neither a comprehensive assessment of public health system issues nor a complete set of viable recommendations for confronting those issues. Rather, the Symposium offers insights and ideas for the future of public health in Pennsylvania. 6 PUBLIC HEALTH IN PENNSYLVANIA: WHERE DO WE GO FROM HERE? This publication in Commonwealth coincides with a time of forward- thinking for public health in Pennsylvania. As mandated by Senate Resolution 194 (Pennsylvania Senate 2007), the Joint State Government Commission is undertaking a review of the state’s public health laws. The Commission’s work will be guided by an Advisory Committee, several of whose members contributed or reviewed the articles appearing in this issue. The review and its recommendations can address longstanding problems with the legal, financial, and organizational aspects of the Pennsylvania public health system. References Federal Reserve Bank of Minneapolis. 2004. “Hospital Beds Per 1,000 Persons, 2004.” Fedgazette. http://www.minneapolisfed.org/Research/data/specmap/us07-01.cfm (Accessed November 30, 2008). Gebbie, K. (principal investigator). 2000. “Public Health Workforce Enumeration 2000.” U.S. Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Information and Analysis. Gostin, L.O. 2000. Public Health Law. Power, Duty, Restraint. University of California Press and Milbank Memorial Fund: Berkeley, CA. Halverson, P.K. “Embracing the Strength of the Public Health System: Why Strong Government Public Health Agencies Are Vitally Necessary but Insufficient.” Journal of Public Health Management and Practice 2002, 8(1): 98-100, at p. 98. Institute of Medicine. 1988. The Future of Public Health. National Academies Press: Washington, DC. Institute of Medicine. 2003. The Future of the Public's Health in the 21st Century. National Academies Press: Washington, DC. Mays G.P., M.C. McHugh, K. Shjim, N. Perry, D. Lenaway, P.K. Halverson, and R. Moonesinghe. 2006. “Institutional and Economic Determinants of Public Health System Performance.” American Journal of Public Health, 96 (3):523-531. National Association of County and City Health Officials. November 2005. Operational Definition of a Functional Local Health Department. NACCHO: Washington, DC. Pennsylvania Senate Resolution 194, 2007, "Directing the Joint State Government Commission to Establish a Legislative Task Force with an Advisory Committee of Experts to Review, Update and Codify Pennsylvania's Public Health Law." http://www.legis.state.pa.us/CFDOCS/Legis/PN/Public/btCheck.cfm?txtType=HTMa ndsessYr=2007andsessInd=0andbillBody=SandbillTyp=RandbillNbr=0194andpn=14 63. Statemaster.com. 2008. Health Statistics. Total Nonfederal Physicians (Per Capita) (Most Recent) by State. http://www.statemaster.com/graph/hea_tot_non_phy_percap-total- nonfederal-physicians-per-capita (Accessed November 30, 2008).