Public Health: What It Is and How It Works, Fourth Edition

1. Public Health:What It Is and How It Works, Fourth Edition Chapter-by-Chapter Power Point Slides Links to Internet-based resources

2. Chapter 4Law, Government,and Public Health

3. Chapter 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

4. 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

5. Federalism and Public Health “Many are the exercises of power reserved to the States wherein a uniformity of proceeding would be advantageous to all. Such are quarantines and health laws…” • T. Jefferson (1807)

6. 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

7. Administrative Law • Separation of powers (legislative, executive, judicial) not apparent in administrative law • Reliance on experts and professionals • Extensive impact on daily life

8. Signs final order advises Recommends decision signs off on rules assists in drafting writes rules witnesses Administrative Law Delegation of Authority Judiciary (Administrative Review Reviews Agencies’ Actions) Legislative Commission (Oversees Rule Making) Executive Department Director Judicial (Decision Making) Chief Counsel Administrative Law Judge or Hearing Officer Legislative (Rule Making) Prosecuting Attorney (Compliance action) Program (Enforcer-Police Power) No Separation of Powers

9. 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

10. Federal Health Agencies

11. Fiscal Year 2007 U.S. Public Health Service Agency Budget Authority. Source: Fiscal Year 2007 Budget, USDHHS, 2006.

12. 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.

13. States with Responsibilities in Emerging Areas of Public Health Practice: United States, 2001.Source: Beitsch et al. AJPH 2006;96:167-172.

14. Selected Organizational Responsibilities of State Health Agencies, 2002. Source: ASTHO 2002 Salary Survey of State and Territorial Health Officials.

15. 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

16. Small, Medium and Large Local Public Health Agencies (LPHAs): Percentage of All LPHAs and Percentage of Population Served,United States, 2005.Source: NACCHO, 2006.

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

18. 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

19. Forces ShapingGovernmental Public Health • “Science and Social Values” • Nature and perceived importance of threats • Relationships among levels of government

20. Influences of Federalism on Public Health Practice • Distribution of power and authority • Origins and evolution • Constitutional/statutory vs. operational impacts • From US Constitution to modern day silos • Public health duties evolved parallel to evolution of federalism • Public health increasingly local

21. 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

22. Total National Health Expenditures, and Federal and State/Local Government Expenditures Spent for Health-Related Purposes,United States, 1960-2003. Source: NCHS, Health United States 2005.

23. Percentage of National Health Expenditures, and Federal and State/Local Government Expenditures Spent for Health-Related Purposes, United States, 1960-2003. Source: NCHS, Health United States 2005.

24. Adjusted total public health spending (in millions) US, 1960-2000

25. Adjusted total public health spending (in millions)from federal and state/local sourcesUS, 1960-2000

26. Per capita public health expendituresfrom federal and state/local sourcesUS, 1960-2000

27. Federal public health spendingas percent of adjusted total public health spending US, 1960-2000

28. Federal public health spendingas percent of total federal health spendingUS, 1960-2000

29. 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).

30. Discussion • What is the basis for the historical tension between the powers of the federal government and the powers of states in public health matters? Provide examples of how this tension is evident in current-day public health activities.

31. Discussion • For the prevention of motor vehicle injuries (see Motor Vehicle Safety in the Century of Progress in Public Health case study), identify at least one responsibility for motor vehicle safety carried out by each of the three levels of government (federal, state, local) through their various agencies. What role does administrative law play in carrying out any of these responsibilities?

32. Discussion • Identify a recent example of public health rules or regulations related to motor vehicle safety in the news media, such as the recall of defective tires. Was the public's health protected by these regulations? Why or why not?

33. Discussion • Compare and contrast the "average" local health department (LHD) in the United States with that of any specific local health department (such as one that you are familiar with or one you found via the Internet). If possible, include comparisons of the type and size of the jurisdiction served, budget, staff, and agency head. Do you find any of these differences to be significant in terms of the ability of the LHD to carry out its role and responsibilities?

34. Discussion • Review the roles and responsibilities for the various federal public health agencies (see Figure 4-1 and Exhibit 4-1 from pages 138-141 of the text) and list the three that you believe are most important. Then examine the various PHS agency budget requests for federal fiscal year 2007 and information on the President's proposals in the most recent federal budget. Is your list of the most important federal public health responsibilities consistent with spending levels for public health activities among these federal agencies? If you could allocate resources differently, which agency budgets would you increase and which would you decrease (assuming the total would remain the same)?

35. Discussion • Use the link to State health agency web sites provided at the Association of State and Territorial Health Officials web site and examine state health department web sites for ONE of the following pairs of states: (a) New York and Massachusetts (b) California and Arizona (c) Washington and Florida (d) Illinois and Virginia or (e) Ohio and Mississippi. Compare and contrast the state-local public health systems in these two states in terms of their structure, general functions, specific services, resources, and other important features. Then identify the three most important differences between the public health systems in these two states. Briefly explain the implications of these differences.

36. 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?).

37. Additional Resources • Invisible Safety Net Video: Part 2--Local Public Health University of Washington School of Public Health and Community Medicine, Northwest Center for Public Health Practice; 1994 • Local Public Health Agency Infrastructure Chartbook NACCHO; 2001 • Plagues and Politics (video history of the US Public Health Service) • State Health Agencies on the Web • State Health facts online • State Public Health Information Data Base and Queries • TOPOFF 2 Legal Handbook (PDF format) IDPH; 2003 • What Is the Structure and Function of Government Public Health Agencies. Public Health Data Standards Consortium