Don’t confuse health care reform with public health

Among the many exaggerated claims made in favor of the health care legislation before Congress is the idea that it would improve the public health system’s ability to manage public health crises like HIV and swine flu.

Unfortunately, public health and health care are different issues, served by overlapping but separate systems. Expanding access to health care does not necessarily lead to gains in public health.

The idea that health care contributes significantly to population health is both intuitively appealing and untrue. Nowhere is this better seen than in the improvement in infectious disease mortality during the 20th century, which was due primarily to non-medical advances, including progress in water and sewage treatment, food safety, insect control, housing, and income. Roughly 75 percent of the improvement occurred before medicine made a serious contribution with the introduction of effective antibiotics in the early 1940s.

Essentially all of the improvement happened before widespread use of childhood vaccines in the 1950s and 1960s. The current health care legislation includes no mechanisms to improve or expand on such broad-based prevention programs.

The primary responsibility for public health, moreover, resides with state governments. Federal agencies such as CDC lack the ability and authority to provide top-down control of the public health system, for both constitutional and practical reasons.

The “police power,” or the ability to regulate common nuisances that threaten a population, is reserved by the Tenth Amendment to the states. Binding policy and implementation decisions are made by state governments, and generally implemented by local health departments, both of which are focused on local concerns. The federal government is largely limited to a supporting role, like assisting with disease investigations or conducting research.

And that’s a good thing. Knowledge of and responsiveness to local needs is an advantage in public health, where local problems vary widely. A county in the Mississippi Delta is likely to be concerned with obesity caused by poverty, while a county with an Indian reservation may see alcohol abuse as a bigger issue. There exists little evidence that federal categorical grants, such as the recent influx of money through the bioterrorism preparedness program, change local priorities in a way that improves population health.

In fact, federal “reform” often hurts the public health system. Both public health and health care experts have criticized Medicare and Medicaid, enacted by Congress in 1965, for changing the focus of health care practitioners from prevention to treatment. Infectious disease mortality rates rose 22 percent in the 1980s (even after discounting for AIDS deaths), despite rising public and private spending on health insurance and medical care. In 1988, the Institute of Medicine warned of a deteriorating public health system. Inadequate vaccine supplies, such as the recent shortages of the measles-mumps-rubella vaccine or influenza vaccines, are at least in part the result of federal attempts to control the production and distribution of the vaccines.