The U.S. Needs a National Public Health System, Experts Say

WASHINGTON — The U.S. needs a more coordinated public health system with a steady supply of funding to states and localities to help them shore up their public health departments, several experts said Tuesday.

“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 such as COVID-19,” said Margaret “Peggy” Hamburg, MD, former commissioner of the FDA, at an online briefing hosted by the Bipartisan Policy Center. “It really reminded us that public health may not lack for effort and commitment, but it does lack for structure, resources, and coordination … We really need to build a strong, robust, sustainable system of public health, a system led at the national level that will promote and protect health day in, day out, but also better prepare us to respond to emergencies.”

Report Proposes a National Public Health System

Hamburg was chair of a nine-person commission sponsored by the Commonwealth Fund that released a 30-page report on Tuesday called “Meeting America’s Public Health Challenge.”

“The healthcare system should work closely with public health agencies, sharing data and workforce and planning together to address a wide range of challenges,” Hamburg said. “This collaboration can lead to progress against many pressing ongoing health challenges, including chronic diseases like diabetes, obesity, heart disease, addiction, and overdose.”

Commission member Julie Gerberding, MD, MPH, former director of the CDC, spoke about the lessons she learned in her time at the agency. “One of the biggest frustrations for me was the coordination of all of these efforts across multiple agencies within HHS, but also across cabinets,” she noted. For example, with the pandemic, “it is a ‘whole of government’ challenge to manage a complex health issue. It’s not just HHS or CDC — it involves [the] Transportation Department, the Education Department, the Commerce Department, the Treasury [Department], and on and on. So, we have to find mechanisms that allow us to do a much better job of coordination.”

“What we’ve witnessed in the past 2 years is an exemplar for disorganization, lack of coordination, under-resourcing, and really a disconnect between the public health system and the healthcare delivery system,” Gerberding said. “Those are exactly the changes that we’re trying to address.”

The report’s recommendations include:

• HHS should develop and coordinate strategies to address core areas of public health infrastructure: data, workforce, laboratories, and procurement
• Congress should establish a position, such as an undersecretary for public health at HHS, to oversee and coordinate the development of the national public health system
• The president should reconvene the National Prevention and Public Health Council to coordinate cross-governmental efforts to advance health and equity
• Congress should provide an adequate and reliable source of federal public health funding to states, localities, tribes, and territories to support a modern public health infrastructure
• In exchange for increased congressional funding for public health infrastructure, states should meet revised accreditation standards and performance requirements demonstrating that foundational capabilities protect every resident
• Health systems, hospitals, community health centers, and other federally supported healthcare organizations should be expected to contribute to public health activities in normal times and during emergencies

New Funding Required

To make these and other changes, “we propose that approximately $8 billion in new investments be dedicated to improving information technology (IT) and public health infrastructure each year — an amount that pales in comparison to the trillions of dollars lost as a result of the inadequate public health response to the pandemic,” the report stated.

“We did not intend this to be another layer of bureaucracy, another layer of delay in getting things done, but in fact, a mechanism to really ensure that we’re thinking broadly about public health,” said Hamburg. “As an agency director, when I headed FDA, I would not have been happy to have another person at HHS telling me what to do across all of the FDA programs and activities. But I would welcome — and I saw on many occasions how it was useful — to have HHS … really focused in on an issue and making sure that all the different partners and stakeholders were at the table making decisions.”

It also was helpful to have the higher-ups “hold different components of government accountable for actions, to ensure that adequate resources were going where they were needed, that there was a comprehensive integrated budget, not just one agency always getting money because they could make their mission sound more compelling or it was more understandable to policymakers,” she added.

Commission member David Lakey, MD, former commissioner of the Texas Department of State Health Services, emphasized the importance of looking at healthcare and public health together. “For too long we’ve been satisfied with sick care — the hospital care system and medical care — being very separate from public health, and that doesn’t work,” he said. “That is a recipe for failure. We really need to integrate those two if we want to be successful not only in emergencies, but to meet the day in and day out needs of our populations we serve.”

How CMS Could Contribute

Some agencies, such as CMS, can play an especially important role in this area, said former Maryland health secretary Joshua Sharfstein, MD. “CMS can be very helpful with overdose and maternal mortality and a number of other areas in partnering with public health,” he noted. “What can that look like? It could start with producing maps of de-identified information and sharing them with state and local health departments. When I was the health secretary in Maryland, we were able to do this with data from CMS and other payers and [were] able to say, ‘Here’s where preventable asthma admissions are coming from; maybe there’s something that we can do there to prevent kids from struggling to breathe.'”

But for these ideas to work, people need to trust the public health system again, Lakey said. “If we go back over a decade, about 43% of the American population had a positive image of public health. Following the pandemic, we’re down to about 34%. And we really need to build that trust if we’re going to drive these programs forward.”

In a Perspective article in the New England Journal of Medicine, the commission members noted, “It will be no small task to pull the U.S. approach to public health into the 21st century, but there are outsized reasons to do so. Establishing a national public health system will save lives from ongoing health challenges, protect our economy during future public health crises, and respect the extraordinary sacrifices of public health and healthcare workers during the pandemic. If not now, when?”