The role of the U.S. government in health policies and programs has its roots in the Constitution. This role is made clear by Lawrence A. Gostin:
The Constitutional design reveals a plain intent to vest power in government at every level to protect community health and safety. By its very first sentences, the Constitution provides sole legislative or policy making authority in the Congress, and the first enumerated legislative power is to provide for the common defense and general welfare of the United States. The legislative role is to enact laws necessary to safeguard the population from harms and promote health (e.g., food and drug purity, occupational health and safety, and a healthy environment) (Gostin 2000, p.2838).
The powers granted to the federal government to regulate interstate commerce, to tax, and to spend have been the most important powers used to protect and promote the health of the population. It was not until the policies advocated by President Franklin Roosevelt in the 1930s, including Social Security, that the welfare clause was used to expand the federal role in domestic social programs. The Medicare program enacted in 1965 to finance hospitals and physicians' services for the elderly and disabled and the Medicare Program—a joint federal-state program to finance health care to certain categories of the poor—was based on the authorities granted in the original Social Security Act of 1935, which represented a fundamental shift in the role of the federal government.
While the Department of Health and Human Services is the lead federal agency on health, the United States government has health functions in over forty different departments and agencies, including the Departments of Agriculture, Veteran's Affairs, Commerce, Defense, Education, Energy, Health and Human Services, Housing and Urban Development, Interior, Justice, State, Transportation, and Treasury, as well as such independent agencies as the Consumer Product Safety Commission, the Environmental Protection Agency, the Nuclear Regulatory Commission, the National Science Foundation, and the United States International Development Corporation, which includes the U.S. Agency for International Development. (For a detailed description of the various federal department, agencies and commissions that carry out federal health functions see: G.T. Kurian, ed. [1998]. A Historical Guide to the U.S. Government. New York: Oxford University Press.)
Policies affecting public health begin with the legislative branch, which consists of the two houses of Congress (the Senate and the House of Representatives). Both the Senate and the House of Representatives affect how or if policies affecting health and environmental programs become law. Congress often determines which federal department or agency will implement these policies. Congress also plays a primary role in the funding of the federal government's public health functions. No money can be spent by a federal department or agency unless appropriated by Congress.
The states play a central role in promoting and protecting the population's health. The states have what are described as reserved powers that permit them to exercise all the powers inherent in government that are neither granted to the federal government nor prohibited to the states by the Constitution. Critical to the states' role in public health are police powers—Gostin defines police power as:
The inherent authority of the state (and, through delegation, local government) to enact laws and promulgate regulations to protect, preserve, and promote the health, safety, morals, and general welfare of the people. To achieve these communal benefits, the state retains the power to restrict, within federal and state constitutional limits, personal interests in liberty, autonomy, privacy, as well as economic interests in freedom or contract as uses of property (Gostin 2000, p. 2980).
The role assigned to the states has made the relationship of the federal government and the states in domestic social programs, including public health, critical to achieving domestic policy objectives. These roles have evolved, particularly since the expansion of the federal role during Roosevelt's New Deal in the 1930s. Federalism, which describes this relationship, traces its roots to the Latin word for covenant. To describe the formation of political society by mutually consenting individuals, the related word "compact" had been used by philosopher John Locke almost one hundred years before the ratification of the U.S. Constitution. In the United States, the ultimate arbiter of the role of the federal government and the states is the Supreme Court. Many courts, including the court as of the year 2000 have been strong defenders of the states' rights against federal domination. Other courts (e.g., the Warren Court) have defined a stronger federal role (e.g., civil rights, women's reproductive rights).
State health agencies and local departments of health are increasingly structured within the framework of federal categorical grant in aid programs for public health, environmental health, and medical care. The multiple departments and agencies at the federal level that fund public health programs are often reflected in the organization of the programs at the state and local level.
THE SIX CORE FUNCTIONS
The role of the U.S. government in protecting and promoting the health of the population is broad and complex, but can be described within six broad functions: (1) policy-making, (2) financing,(3) public health protection (e.g., standard setting and regulation), (4) collecting and disseminating information, (5) capacity building for population health, including research and training, and (6) direct management of health services. The interactions of the three branches of the federal government with each other and with the state governments are critical to the performance of each function. This article, however, focuses on the executive branch of the federal government. The policy-making involves Congress, the president, cabinet secretaries, and their key staffs. The judicial branch may play a key role (e.g., abortion, civil rights, environmental health, federal-state roles). Financing depends first and foremost on the authorization for and appropriation of funds by Congress. After these funds are appropriated there is control by the Office of Management and Budget in the White House, with the actual distribution of funds by the departments and agencies (e.g., Health Care Financing Administration). All the other activities are primarily carried out by departments and agencies, with oversight by the White House and Congress.
All of the six basic functions must be effectively performed at the federal level for an effective federal health function. When working in a coordinated fashion, these independent functions create a synergy that supports a population-based approach to health. The current priorities and the organization of federal health programs, however, reveal a confusion about the federal health mission and how to organize to achieve it. In terms of expenditures, the highest priorities are financing medical care for individuals and biomedical research. Public health priorities have been reflected in multiple-disease focused, categorical public health programs that are more often treatment than prevention oriented.
An alternative priority for federal health action would be to set as a goal the 1988 definition of the mission of public health by the Institute of Medicine's Committee for the Study of the Future of Public Health:
The Committee defines the mission of Public Health as fulfilling society's interest in assuring the conditions in which people can be healthy. Its aim is to generate organized community efforts to address the public interest in health by applying scientific and technical knowledge to prevent disease and promote health. The mission of public health is addressed by private organizations and individuals as well as by public agencies. But the governmental public health agency has a unique function: to see to it that the vital elements are in place and that the mission is adequately addressed (IOM 1988, p. 5).
Little emphasis has been placed on this public health mission and on capacity building for population health, or on collecting and disseminating information on the health of the population, particularly at the state and local level.
Policy-making. Health policy-making is a critical function of the federal government. It involves creating and using an evidence base, informed by social values, so that decision makers can shape legislation, regulation, and programs to achieve the agenda of national leaders. This involves interaction of executive and legislative branches, influenced by a variety of stakeholders in the nongovernment sector, and often tempered by action by the judicial branch.
Policies are reflected in the legislation authorizing particular programs, and in the appropriation of funds by Congress for particular purposes that do not require a special legislation (e.g., Healthy People 2010).
The judicial branch can affect federal public policy and its public health functions by modifying the legal basis for public health initiatives in decisions rendered by federal courts, including and the U.S. Supreme Court. While Congress must enact the laws that establish federal public health policies and appropriate the funds to implement these laws, the judicial branch can influence public policy in the United States by interpreting policies in relation to the Constitution and federal laws. For instance, the Supreme Court, under Chief Justice Earl Warren, made decisions of fundamental importance in two areas directly related to the public's health: civil and reproductive rights. More recently the Rehnquist court has limited the interpretation of the commerce clause by the Congress.
Depending on the priority placed by the president in health issues, many public health and environmental health policy proposals develop in the White House, including the Office of Management and Budget (OMB), as well as by cabinet departments, independent agencies (e.g., EPA), and commissions (e.g., Consumer Product Safety Commission). Within the executive branch, health-policy direction comes from the Executive Office of the President, particularly the Office of Management and Budget, the Council on Environmental Quality, and the Domestic Policy Council (directed by a special assistant to the president).
The U.S. Department of Health and Human Services (USDHHS) plays a major role in initiating, shaping, and ultimately implementing and monitoring the effects of legislation passed by Congress and signed by the president. It does this in coordination with the Executive Office of the President, particularly the Office of Management and Budget (OMB), Congress, state governments, regulated industries, providers, beneficiaries, and other interest groups. The position of Secretary of Health and Human Services has the widest responsibilities over the public health programs at the federal level, but this role is limited because of this wide dispersion of federal public health and medical care programs. The organization and management of USDHHS was changed substantially in 1994, when the Social Security Administration (the core of the department from 1953 to 1994) was removed from USDHHS by Congress and established as an independent agency. In 1995 the secretary assumed direct authority over the eight agencies of the U.S. Public Health Service (PHS), designating them as operating divisions reporting to the secretary. The assistant secretary for health thus became a staff officer not a line manager. Another factor affecting the secretary's role was the enactment of welfare reform in 1996, which eliminated federal welfare programs that had operated for over sixty years and transferred the policy and program decisions to the states—with federal financial support but little policy direction. The decreased role of welfare policy increased the relative importance of the health policy and program role of the secretary.
The secretary delegates responsibility to the components of USDHHS. The Center for Medicine and Medical Services (CMMS), the Administration on Aging (AOA), the Agency for Children and Families (ACF), and the operating divisions of the U.S. Public Health Service (i.e., the National Institutes of Health [NIH], the Centers for Disease Control and Prevention [CDC], the Agency for Toxic Substances and Disease Registry [ATSDR], the Health Resources and Services Administration {HRDA], the Substance Abuse and Mental Health Services Administration [SAMHSA], the Indian Health Service [HIS], and the Agency for Healthcare Research and Quality [AHRQ]). The secretary's role as the country's chief public health official goes beyond the administration of federal programs, because the secretary serves as the president's principal health advisor.
Financing. The federal government plays a very large role in the financing of health care. In Medicare, the federal government directly finances the health care of the elderly, but Medicare only covers about 50 percent of the cost of health care for the elderly (e.g., it does not cover prescription drugs). The federal government also provides a large subsidy for state Medicaid programs, providing 50 to 80 percent of their funds. Federal employees have their purchasing of health insurance subsidized by the federal government, as do the dependents of military personnel.
Medicare, Medicaid, and the State Child Health Insurance Programs (SCHIP) are administered by the Centers for Medicare and Medicaid Service (CMMS). Through these programs, CMMS provides health insurance directly or indirectly to over 74 million Americans. To run these programs, CMMS has a relatively small staff to implement policy through regulations and oversee the performance of the insurance companies that administer Medicare Part A (hospital insurance) and Part B (medical insurance) and pay the providers for services rendered. These are called fiscal "intermediaries" (Part A) and "carries" (Part B). The CMMS also oversees the state agencies that administer Medicaid and SCHIP. It is also the responsibility of CMMS to combat fraud and abuse in the Medicare and Medicaid programs. Additional responsibilities for CMMS include setting national policies for paying health care providers, conducting research on the effectiveness of health care services, and the enforcement of the policies related to the quality of health care services. The regulation of clinical laboratories performing tests on patients paid by Medicare also falls under the jurisdiction of CMMS with advice from CDC.
Public Health Protection. Public health protection is the most classic of the public health functions performed by the federal and state governments. Governments at all levels use their health status and disease surveillance capacity to assess health risks and use their standard-setting and regulatory powers to protect the public from these risks.
Based on the scientific evidence available through risk assessments, standard setting and regulation at the federal level involves four broad areas: (1) provider certification (e.g., for clinical laboratories through the Clinical Laboratory Improvement Act and certification of providers such as hospitals who meet the standards of the Joint Commission on Accreditation of Healthcare Organizations and thus qualify for Medicare payment); (2) purchaser and insurance certification (e.g., through collaboration with states to establish criteria for financial viability of health plans and health insurance entities that permit them to operate in the market place); (3) standard setting (e.g., for age appropriate clinical preventive services, immunization schedules, clean water, air quality, and workplace safety, as well as health care quality standards set by HCFA for providers of health care to receive Medicare funding); and (4) regulations (e.g., for the safety and quality of foods; the safety and efficacy of prescription drugs, biologics such as blood products and vaccines, medical devices, and cosmetics; highway safety; occupational health and safety; air and water pollution control; pesticides; radiation; toxic wastes; and consumer products.)
Financing agencies, such as HCFA (which administers Medicare and Medicaid), also implement regulations to assure compliance with the intent of Congress with respect to the administration of programs. Types of regulatory measures include command and control regulations, performance standards, and guidance documents. An example of the regulatory power the federal government has is the power to issue a health provider and/or purchaser/insurer certification; as in 1966, when hospitals had to be certified that they were in compliance with the Civil Rights Act of 1964 (e.g., that they barred segregation) in order to receive Medicare payments. Over 3,000 hospitals had to desegregate prior to the implementation of Medicare on July 1, 1966, in order for them to receive Medicare payments.
The basis for standard setting in regulating remains grounded in science; the research base is largely generated by DHHS agencies. These regulations are reviewed by USDHHS and OMB before they become final.
The principal federal regulatory agencies are the Food and Drug Administration (drugs, biologics, medical devices, cosmetics), the Department of Agriculture (meat, poultry, and eggs), the Department of Energy (radiation-related environmental management, civilian radioactive waste management), the Department of Labor (occupational health and safety), the Department of Transportation (auto and highway safety), the Department of Treasury (alcohol, tobacco, and firearms), as well as the Centers for Disease Control and Prevention and HCFA (clinical laboratories, health care providers), the Environmental Protection Agency (air and water pollution control), the Consumer Product Safety Commission and the Nuclear Power Regulatory Commission.
Collecting and Disseminating Information. The federal government is responsible for the collection and dissemination of information relating to public health and the health care delivery systems. This part of the assessment function is critically important to public health practice and risk assessment. The U.S. Census carries the most basic of the federal data collection responsibilities. The National Center for Health Statistics (NCHS) in HHS is the primary agency collecting and reporting health information. Data gathering for public health purposes is a shared responsibility with state and local governments. The collection and dissemination of information includes at least six functions: (1) reporting requirements for federal grant-in-aid funded programs; (2) disaster surveillance; (3) national vital and health statistics;(4) population surveys (e.g., Health Information Survey, National Health and Nutrition Examination Survey); (5) health care cost, delivery, and utilization information; and (6) research findings. The federal government presents information about the health of the nation through its annual publication Health, United States. It also publishes many other reports. Particularly important surveys conducted by the NCHS are the Health Interview Survey and the National Health and Nutrition Examination Survey (NHANES). The Agency for Healthcare Research and Quality (AHRQ) conducts the National Medical Care Expenditure Survey, while the Health Care Financing Administration (HCFA) conducts the Medicare Beneficiary Survey and it also collects and disseminates information on national health expenditures.
In the future, the development of the National Health Information Infrastructure will be critical to enhancing the capacity for collaboration among the federal, state, and local governments. The proliferation of categorical public health programs (there are more than 200) at the federal level has made coordination and collaboration more complex and more difficult at all levels of government.
Capacity Building for Population Health. Capacity building for population health must assure the ability of federal agencies to effectively discharge their responsibilities to promote and protect the health of the population. It must also assure that other levels of government, which share responsibilities for health, have the resources— human, financial, and organizational—to carry out their responsibilities, whether delegated to them by the federal government or those for which they have primary responsibility.
The major federal investments in capacity building have supported biomedical research, human resource development, and capital development of facilities (e.g. hospitals) for personal health care services and biomedical research, mirroring the federal health policies that support the financing of health care and biomedical research.
The research and training function is dominated by the support of biomedical research (basic and clinical) by the National Institutes of Health. Located in Bethesda, Maryland, the National Institutes of Health (NIH) comprises twenty-seven separate institutes and centers, including the National Institute of Environmental Health Sciences, located in North Carolina. The NIH approached $20 billion dollars in 2001. The mission of NIH is to help fund work in its own laboratories and in universities, hospitals, private research institutions, and private industry to uncover new knowledge that can potentially improve the quality of medical care and the understanding of disease processes. While part of the PHS, the research at NIH is focused primarily on basic biomedical and clinical research, with little emphasis on the health of the population (e.g., determinants of health) or prevention. The NIH also supports research training, but in a more modest scale than in the past.
The largest support for health professions training consists of Medicare's funding of graduate medical education (GME). Funding for GME provides direct salary support of residents in training in hospitals caring for Medicare patients (called direct medical education payments) and payment to teaching hospitals for the higher costs of treating Medicare patients in teaching hospitals (indirect medical education payments). The GME payments dwarf the funding for health-profession training funding by the Health Resources and Services Administration or other operating divisions within USDHHS.
Health-services research is supported very modestly, and far below what is needed. Public health research and training is a third category that receives only limited support by the USDHHS, particularly through CDC and HRSA.
There never has been a systematic or adequate federal investment in public health infrastructure (e.g., public health laboratories), broad-based information systems for disease surveillance or environmental risk, population health, water quality, food safety) and population health education and work force training. Compared to the billions spent by Medicare to support graduate medical education, the federal government spends less than $5 million annually for public health training.
Collaboration among agencies (departments within the federal government) to promote population health requires managerial capacity building, particularly information systems to meet the needs of various collaborating agencies that go beyond the limited data systems that serve primarily to assure program accountability. This is often made more difficult because Congress sometimes places increased demands on agencies (e.g., FDA, HCFA) but reduces their budgets for the administrative support required to meet their expanded responsibilities.
Federal-state relations are a particularly important area for capacity building. The federal government is already using intermediaries, including state and local governments, for much of what it does.
Direct Management of Health Services. The Department of Defense, including the Army, Navy, and Air Force, the Indian Health Service of the U.S. Department of Health and Human Services, the Department of Veteran Affairs carry out the direct management of public health and medical services. The U.S. Public Health Service also provides commissioned officers to provide medical care to prisoners in federal prisons and to members of the Coast Guard. The medical care previously provided to merchant seamen through a system of public health service hospitals and clinics was eliminated during the Reagan administration.
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—— (2000). "Public Health Law in a New Century, Part 2: Powers and Limits of Public Health." Journal of American Medical Association 283:2980.
Institute of Medicine, Committee for the Study of the Future of Public Health (1988). The Future of Public Health. Washington, DC: National Academy Press.
Kincaid, J. (2001). "Introduction: Federalism Values and Health Values." SciPolicy Journal 1(1):1–17.
