Public Health in the New American Health System

Abstract

Health reform is now moving beyond academic dialogue toward governmental implementation. Across the nation, a consensus has emerged that the nation's health system is in need of repair. President Clinton has made health reform one of his top priorities, and Hillary Rodham Clinton headed the task force that developed the administration's proposal for reform. Many other key players, including members of Congress, business leaders, health care providers, health insurance companies, and professional organizations have made it clear that they, too, are ready to work together toward a plan for the reform of the nation's health system. While it is not yet clear precisely what form the new American health system will take, we do have some indications as to what it might include based on recent discussions and debate. To date, discussions of health reform have focused almost exclusively on questions of how to extend health insurance to the nation's 35-40 million uninsured and, at the same time, bring medical care costs under control. These are, unquestionably, issues of great importance. There is danger, however, in limiting the discussion to issues of access and financing within the medical care sector. While the importance of increasing efficiency and improving access cannot be overstated, these issues alone do little to address the broader mission of the nation's health system--improving the health of the American people. While improvements in the medical care sector may contribute to better health outcomes for some individuals, it is unlikely that such changes alone will have a significant impact on measures of the nation's health. For health reform to be successful, health care reform must be accompanied by reform of the nation's public health system. That is: Health Reform = Health Care Reform + Public Health Reform Taken together, health care reform and public health reform can produce a more efficient, more equitable health system that actually improves the health and quality of life of the American people. We appreciate the opportunity to comment on this timely topic, in conjunction with Rundall's article, Integration of Public Health and Medicine. In many respects, our thinking, which reflects many discussions during 1992 and 1993 at the Centers for Disease Control and Prevention, parallels that of Rundall. We believe that health (care) reform offers a real opportunity to reform our overall health system, bringing public health and medical care into proper focus and integrating them in a sensible fashion. WHAT IS PUBLIC HEALTH? The American health system can be viewed as the union of two components--the health care (or medical care) system and the public health system. These two components are not independent and should not be viewed in such a way; indeed, the more independent each is, the less effective both become. Rather, the health care and public health systems do, and must, complement and interact with each other. Whereas the health care system tends to focus on the treatment of medical problems, the public health system's emphasis is on disease prevention and health promotion. While the health care system provides medical services to individuals seeking care, the public health system targets health services through community programs directed at population groups. Indeed, many definitions of public health exist, but nearly all share the recognition that prevention and the health of the community are central to public health. While most people have a general idea of what public health is, the public health system's organization and scope of activities are unclear even to many health professionals. In broad terms, as described in the Institute of Medicine's report, The Future of Public Health (1988), public health agencies perform three core functions: 1. Assessment: regularly and systematically collecting, assembling, and analyzing information on the health of populations, factors affecting people's health, and the health system itself. …