“The national response to the COVID-19 pandemic exposed profound weaknesses and disorganization in the U.S. public health system,” says David Blumenthal, president of the Commonwealth Fund, a philanthropic organization engaged in health and social justice issues.
The Commonwealth Fund convened a panel of leading health experts charged with rethinking the nation’s public health system. Their recommendations have just come out.
They come in four main flavors. One is a call for the federal government to do a better job of coordinating its own capabilities and resources. Another is for Congress to provide a steady stream of funding to state, local and tribal health departments — to the tune of $8 billion annually. They call on hospital systems and health-care providers to integrate more closely with health departments. And they note that public health officials themselves must do a better job of communicating with the public and earning back its trust.
“The COVID-19 crisis shone a very harsh spotlight on many of the longstanding gaps in public health and its ability to respond to both day-to-day concerns and to a crisis,” says Margaret Hamburg, a former Food and Drug Administration commissioner who led the effort. “We need more than ad hoc strategies.”
There’s no guarantee that Congress — which no longer appears interested in providing funding for the current pandemic, let alone worry about future reforms — will respond to the recommendations. But it’s clear no one would design the system as we have it now, which makes serious efforts at rethinking public health valuable.
Public health is as decentralized as any other function of government — and more fragmented than most. The federal government has never had a public health agency with broad powers to respond to emergencies and ongoing challenges. The federal Centers for Disease Control and Prevention (CDC) has typically played a leading role, outlining strategies that are then carried out by states and localities, with Congress coming in later to backfill the funding. That model broke down during the coronavirus pandemic.
Instead, the nation has seen a response that’s varied greatly from place to place. Both the disease and the responses to it became polarized, with not just different but often opposing strategies pursued in Republican- and Democratic-led jurisdictions. “The challenges of earning trust are particularly high, and it’s difficult to do so in the sea of misinformation we find ourselves in,” says Joshua Sharfstein, a vice dean at the Johns Hopkins Bloomberg School of Public Health, who worked on the Commonwealth Fund report.
Not Really a System
It’s common to refer to the American health-care “system,” but in reality the vast and sprawling networks of hospitals, community health centers, doctors' offices and urgent care clinics are in barely any kind of communication with each other. As far as government goes, there’s an alphabet soup of agencies at the federal level that don’t coordinate well with one another, let alone the nearly 3,000 state and local health departments nationwide.
“Absent an official or office to lead public health efforts, HHS (the federal Department of Health and Human Services) has had difficulty coordinating the work of the large and powerful agencies that are essential to public health, both within the department and elsewhere in the federal government, and with nonfederal partners,” the Commonwealth Fund report concludes.
Rather than creating a new public health department, the report calls for creating an undersecretary of public health within HHS. The idea is not to create a new layer of bureaucracy, Hamburg says, but rather to put someone in charge to make sure agencies know who is accountable for what and to ensure budgets are aligned with priorities. “Creating an undersecretary position brings HHS in line with other departments,” she says. “We don’t need to wait until we have congressional approval. There are things the HHS secretary can do right now.”
Among other changes, the report recommends that the White House convene a standing council to coordinate federal public health efforts with states, localities, tribes and territories. As noted earlier, the report also recommends increased funding from Congress to support these governments.
State and local health officials have long complained that they don’t get enough help from Washington — and that it’s the wrong kind of help. Money comes pouring into health departments following emergencies such as Ebola or the 2001 terrorist attacks. But it’s nearly all earmarked for specific purposes and can’t be used to address other ongoing challenges.
That includes building capacity in areas such as data infrastructure. The difficulties of accessing and using basic information, even about cut-and-dried figures such as the number of deaths, have been a sore spot — or rather a blind spot — throughout the pandemic.
“Our systems are archaic,” says Julie Gerberding, a former CDC director who worked on the Commonwealth Fund report. “Some jurisdictions are still sending information back and forth by fax.”
Meeting Minimum Standards
In order to receive increased federal funding, state and local departments would have to demonstrate their ability to deliver on a set of core functions. The Commonwealth Fund report calls on the administration to rethink the accreditation system for health departments, to make sure they can all function at a certain level.
“Where you live should not determine how well your health department protects you from public health threats,” according to the report. “That is not the case today, and no basic standard has been set for public health capabilities.”
Few small health departments employ an epidemiologist; many who do have one working only part time. “It’s hard to do public health if you don’t have someone who knows how to gather that data,” says David Lakey, a former Texas health commissioner.
The U.S. spends vastly more on health care — treating individual patients for disease or injury — than it does on public health, which is dedicated to trying to change conditions that lead to disease or injury. It’s important, Lakey says, for health-care providers to share data with health departments so they can spot challenges in terms of infectious or chronic diseases.
It’s time for the Centers for Medicare and Medicaid Services (CMS) to demand more information sharing from private providers, says Sharfstein, the Johns Hopkins professor. The more information that gets shared, the better prepared health departments will be when there’s an emergency.
"Let’s be honest: CMS has some pretty serious leverage over the health-care system,” he says. “It’s important that the federal government use some of that leverage to set some standards and basic expectations.”
