Policy Point/Counterpoint

Policy Point/Counterpoint

Missing in Action: A Recognizable Public Health Voice

According to a recent National Association of County and City Health Officials (NACCHO) survey, governmental public health lost 19 percent of its workforce between 2008 and 2010. If we’re going to reverse that slide, we need to show why public health is so important. The Affordable Care Act (ACA), which has a number of highly desirable population-health provisions, will go some distance toward doing that. The act requires nonprofit hospitals and health care systems to conduct community-needs assessments and implement those findings, and it establishes significant prevention and wellness programs. Although it fails to offer a systematic approach to public health, ACA deserves widespread support from the public health community.

This support will be especially crucial in the next three years, as opponents of the act increase their efforts to overturn the public health provisions of the act. The public health community must mount a cohesive response—a challenge all the more difficult given the absence of a unified and identifiable public health voice.

A recognizable public health voice has been missing in action since shortly after World War II, when passage of the Hill-Burton Act launched a nationwide medical/industrial complex, and medical care began to dominate how we think about health care generally. The lack of a unified public health voice means two things.

First, public health has limited political influence. Second, it means fragmented advocacy for public health issues. The monolithic tobacco industry speaks with a unified voice, as does the National Rifle Association. When giants like these move to oppose an issue, legislators tremble. Public health has no comparable clout. There are exceptions, of course, such as the Campaign for Tobacco-Free Kids, but even at the state level public health advocates have limited political influence.

Obviously, we needn’t agree on everything. And while a unified voice is hardly a panacea, on the big issues we must seek to speak with a single, clearly audible voice. Right now, our most immediate concern should be the preservation of ACA. We need a major effort to ensure that population health resides at the core of a reformed health care delivery system in the United States. The greatest advances in reducing morbidity and extending life expectancy have come through public health initiatives. Yet public health has done a poor job of explaining what population health is, why it matters, and why a robust public health system is more essential to improving health status than a much greater investment in medical care and technology.

What good is technology if we don’t confront the obesity epidemic? What good is it if we lack the mechanisms to prevent the spread of infectious disease?

I propose three action steps:

  1. We need to advocate for population health to be incorporated into all health-related policies at the federal, state, and local levels, including Medicare and Medicaid. If we’re serious about reducing long-term medical costs, this country needs to invest in population health.
  2. We need a major educational campaign to remind people why public health matters to everyone, and to demonstrate why funds spent on public health are essential investments in our future. Schools of public health ought to be major players in this. The Association of Schools of Public Health and UM SPH should lead the way.
  3. We need a stronger consolidated voice at the national level. Just as health insurers consolidated into America’s Health Insurance Plans, the national public health organizations—NACCHO, the Association of State and Territorial Health Officers, the American Public Health Association, and the National Association of Local Boards of Health—need to develop some type of formal overarching structure so that they are linked in the public’s eye and have greater visibility in advocating for policy change.

We can’t afford to miss this opportunity. We can’t let opponents of ACA erode its many good provisions for population health. We can’t afford to see our states’ ability to fund public health continue to decline. If we don’t get this right, and soon, governmental public health will continue an inexorable—but not inevitable—slide into irrelevance.

Author Peter Jacobson is a professor of health law and policy at UM SPH; director of the UM Center for Law, Ethics, and Health; and president of the Public Health Law Association.

It’s Not about Voice—It’s about Politics

I don’t believe that magic will occur if we in public health simply align ourselves and speak with a single voice. The problem is both more fundamental and more complex than that. First of all, we need to recognize that state and local public health officials are answerable to elected officials, and we have to learn to speak the language of those officials. So far we haven’t done that especially well. Beyond wrapping ourselves in our moral white coat and saying it’s the right thing to do, we haven’t done a good job of explaining the value of public health in terms that elected officials can understand and embrace.

We need to quantify what we do in terms that are meaningful to policymakers. If we’re talking about maternal and child health issues, for example, can we demonstrate an improved readiness to learn at school age?

We need to be aware of the limitations of policymakers. When we talk about a preventive payoff in a time frame that’s well beyond the period of any given appropriation cycle, that creates a very challenging political dilemma. When we say, for instance, that “every dollar spent on immunizations saves eight dollars,” we need to quantify that by indicating who will actually save, and when that savings will be realized. We haven’t done a good job in thinking about public health economics in a way that starts to grapple with these kinds of measures.
We need to be open enough to rethink how we describe and quantify the benefits of public health for different constituencies. Perhaps we should ask others besides ourselves what public health is or ought to be. One way to influence elected officials, for example, is by influencing the electorate. It’s a whole lot more powerful for an elected official to hear from a key constituent about the need for an improved public health system than it is to hear that from someone within the public health system.

We have to do a better job of quantifying things that we now describe as intangible, such as social justice or even the notion of “improved quality of life.” How readily understandable is that measure among policymakers? We have to get beyond our typical “years of productive life” and “morbidity and mortality” and rethink our basic issues of measure.

And we need to get over our discomfort with short answers. How many times do we say something and immediately follow it with “but on the other hand” or “more information is needed”? We’re reluctant to move and to move quickly. We don’t know the language of public advocacy. I had an elected official—a friend to public health—say to me once, “You public health people make it so easy to say no. You equivocate. You rarely make it definitive.”

It’s false thinking to assume that if we only get the message right, everyone will be on board.

Public health people are for the most part answerable to elected policymakers, and I think we have trouble with that within the public health system. It’s part of a larger problem, which is a general lack of understanding of how government systems work in this country. I think that civics, and governance and government, should be a part of the public health core competency. Only by understanding how governance works in this country can we begin to think about approaches to advocacy. We have, for better for worse, a system of governance in which policy relative to public health is not vested for the most part directly in public health professionals. We need to understand that better and work with that.

Author Patrick M. Libbey is a clinical instructor in the Department of Health Services at the University of Washington and a consultant to the Robert Wood Johnson Foundation. He served as executive director of the National Association of County and City Health Officials (NACCHO) from 2002 to 2008, and was director of the Thurston County (Washington) Public Health and Social Services Department from 1984 to 2002.

YOUR THOUGTS? Enter them below:

Editor’s note: This is the first in a new series of opinion pieces for Findings. We welcome suggestions for future “Point-Counterpoint” editorials. Submit YOUR ideas in the comments section at the bottom of this page or e-mail sph.findings@umich.edu.