HomeMy WebLinkAboutAgenda - 03-09-1999 - III-BORANGE COUNTY
Board of Commissioners
Action Agenda
Item No._IIL B._
Action Agenda Item Abstract
Meeting Date: March 9,1999
Subject: Orange County Health Department as the Safety Net Provider
Department: HEALTH Public Hearing Yes X No
Budget Amendment Needed Yes X No
Attachments(s): Core Public Health Functions, NACHO 1993 Information Contact:
Excerpt from New Partnerships for the Future of Public Health Health Director's Office X2411
"Future Trends Affecting Public Health Challenges & Opportunities" Telephone Number
"Prevention, Public Health, and Managed Care" Hillsborough - 732 -8181
Excerpts from Access to Health Care in North Carolina 1996 Chapel Hill - 968 -4501
Orange County Data from 1998 NC Data Guide to Child Well -Being Mebane - 227 -2031
Durham - 688 -7331
Purpose: To discuss jointly the philosophy, need, and implications for the Health Department to be the "Safety
Net Provider" of health services.
Background: The rapid change in the health care system has brought a plethora of new forms of financing and
delivering health services. Even with the increased focus of managed care organizations on the need for
community prevention programs, there is still a large number of citizens that remain without a regular source of
health care. While those in poverty qualify for Medicaid, in some communities private providers are reluctant to
accept Medicaid patients. One example in Orange County is the reluctance and often outright refusal of private
dentists to accept Medicaid clients. The most consistent providers of those services are the UNC Dental School,
Piedmont Health Services with its new dental program, and the Orange County Health Department. Dental health
is only one example offered. Physicians are more likely to accept Medicaid clients into their practices because the
reimbursement is at least at a more competitive level than dental reimbursement, however many physician
practices "limit" their Medicaid enrollment. In addition to the Medicaid population, there is a significant portion
of the population that is uninsured, either because they cannot afford private insurance rates or because they are
small business owners who cannot afford health care coverage. A third population is the growing Latino
population that often do not qualify for state or federal funds because they are undocumented aliens. A typical
situation might be that the father is employed and has a work permit, but either the wife or the children or both are
not "registered.
As the health department considers future plans for delivering services to clients, it would be good to have some
direction from both boards regarding this issue.
Recommendation: To receive the information and to discuss the issues.
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PUBLIC. HEALTH FUNCTIONS.
K]
July 1993
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National
Association of
County Health
Officials
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Public health should be a critical element in any health care system and should be included in any reform
proposal. Public health services are population - based, i.e., they are services andinterventions whichprotect
entire populations from illness, disease and injury. Population -based services are essential to any effort to
address such problems as spiraling health care costs, lack of access to care, and the poor health status of too
many U.S. residents.
With the recognition of public health as akey component in the health care system comes the responsibility
to better define the specific services provided under the auspices of public health. What is public health?
How does itfitwith the otherpiecess ofthehealthcut system? Andwhich ofthe functionsprovided through
state and local public health agencies are essential, or "core" functions?
This document is intended to provide a common definition of core functions that will allow public health
officials and lawmakers to:
• agree upon those functions which are essential, and require adequate base funding support; is
• reach a common understanding of population -based health services and the critical role such
services play in health care reform; and
• determine which services will be purchased through a set aside of health care expenditures,
created for public health activities.
The document is being offered as a basis for discussion by NACHO members, as they address the issues of .
national health care reform.
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Core Functions
Assessment of community health status and available resources.
Policy Development resulting in proposals to support and encourage better health.
Assurance that needed services are available.
The mission of state and local health agencies is to protect and promote health, and prevent disease and inj ury.
Public health services are population -based —that is, services which are focused on improving the health
status of the population, as opposed to the treatment of individuals. This mission is the responsibility of the
federal public health agencies, the 5o state departments and the 3,000local public health agencies nationwide.
To accomplish this mission, public health agencies balance three core government public health functions.
These functions are essential to the maintenance of population -based services:
First, public health agencies assess community health status and whether the community has adequate
resources to address the problems that are identified
Second, they must use the data gathered through assessment to develop health policy and recommend
programs to carry out those health policies.
Finally, they must assure that necessary, high quality, effective services are available. This includes a
responsibility for quality assurance through licensing and other mechanisms.
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Assure does not always mean provide. Rather, it is the responsibility of a government public health agency
to see to it that services are somehow available to people who need them. Typical providers include private
practitioners and non -profit agencies, including community health centers, as well as government public
health agencies themselves.
Too few resources have been available to meet the three core government public health functions. Most of
the resources available are spent on assurance and are limited to specific programs. Assessment and policy
development are neglected.
If public health is to be an effective component of health care reform, the public health system must be
improved. AstrongergovernmenthmMsystem— worldngactivelytoprotectandpromotehealth and
prevent disease and Injury—will ultimately result in costsavings and less demand for more expensive
dlness care.
Assessment
Assurance
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Development
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Examples of Services
Health Surveillance Programs:
• Vital statistics - monitoring death certificates for unusual patterns of infant and
other mortalities according to cause, race or residence.
• Communicable disease reporting - following the incidence of cases of
gastroenteritis to find epidemics such as the hamburger- related E. coil illness
In Washington State in 1993.
• Chronic disease registries - such as the birth date= registry which helps
identify unusual clusters of birth defects and their causes.
Health Protection Programs:
• Drinking water monitoring - to identify bacterial or chemical contamination of wells
or water supplies before people in the community are made ill.
• Food sanitation - inspecting restaurants to prevent poor food handling practices
that could spread hepatitis or gastroenteritis.
• Toxic chemical regulation - monitoring storage and disposal of chemicals to
protect neighbors, children or workers from toxic exposure.
• Occupational safety - conducting studies of occupational illness and injury and
Intervening as necessary.
. Personal Preventive Services:
• Immunization - requiring school entry Immunization to protect children and the
community from outbreaks of diphtheria, measles, and polio.
• Communicable disease investigation - investigating cases of tuberculosis to
identify contacts and protect others from spread of the bacteria.
Health Promotion Programs:
• Alcohol and drug education - informing teenagers of consequences of alcohol
and drug use; drinking and driving - to protect others in the community as well
as protecting youth.
• Tobacco control - smoking education and regulation of availability of tobacco to
youth in order to prevent lung cancer and heart disease.
• Injury and violence prevention - organizing community-wide initiatives to
prevent intentional injuries and violence.
Services Which Improve Access to Care:
• Information and referral - assisting the needy and disabled in finding appropriate
health care facilities.
• Public health nursing home visits - Identifying families needing prenatal care,
child health care or child abuse prevention.
• Case management - providing supervision and coordination of health care for
the chronically mentally ill and disabled.
• Facilitating new resource development - working with hospitals and physicians
to establish needed services, clinics or programs.
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The application of population -based health services in this century has saved millions of lives and resulted
in the virtual elimination of a number of infectious diseases in this country, e.g., cholera and yellow fever.
Smallpox has been eradicated worldwide.
Earlierin this century, it was increasingly recognizedthatpeople could transmit disease to one another. The
role of state and local public health agencies greatly expanded, and mortality and morbidity rates from
diptheria, polio, typhoid, and other contagious diseases were significantly lowered.
Public health efforts directed at preventing present day health problems are expected to yield similarresults.
The Institute of Medicine and the Centers forDisease Control have recently emphasized the importance of
population -based efforts to the health of the nation, i.e., services which target the health status of the entire
population, as opposed to personal health care services administered after a person becomes ill.
Population -based services focus on the identification of health threats, community health protection,
screening and prevention services, health promotion programs and services that improve access to care;
* Surveillanceofthehealthstatusofthecommunitytoidentifyunusualpattemsofillness
and death, and to investigate their causes.
*Monitoring drinking water, food sanitation and waste disposal in order to protect the
health of the entire community.
*Providing immunization or screening to high risk individuals to protect them as well
as their families and communities from communicable disease.
*Offering education andiuformationonhealthybehaviors andhealthylivinginorderto
promote better health for all
*Improving access to health care through information, referral, outreach and case
management, as well as community planning and program development.
Efforts to promote personal health, protect community health and prevent disease are known to be effective.
However, an inadequate amount of current health system dollars is spent on these services. Increased
emphasis on population-based services will help contain avoidable costs and decrease premature loss oflife.
Six percent of national health care expenditures should be set aside to fund public health services.
Population-based services are a major contributor to overall improvement of health status. Prevention,
promotion and protection strategies need to be thought of as an integral part of the larger health cake system.
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Data Sources
Personal Health Data:
• Vital statistics
" Epidemiology- surveiNance, disease reporting
& investigation, sentinel events
Health screening
• Special disease or population registries
" Laboratory test data
• Hospital discharge data
' Research
* Behavioral Risk Factor Surveys
Environmental Health Data:
• Sanitary surveys
• Air & water monitoring
• Facility inspections
• Laboratory test data
• Research
Data about community concerns and resources:
• Health resource inventory
* Public forums
• Polling
• Special methods- APEX/PH Part ll, PATCH, eta
• Information from private & non -profit providers
• Research
Date on the range & quality of services:
• Selected treatment management review data
• Consumer complaint follow -up information
• Facility & professional licensure data
• Research
Methods of Distribution of Findings
• Annual vital statistics report
• Special project Worts
• State Health Report
• Monographs
• Fact sheets
• Professional publications
• Media releases
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Assessment means the regularcollection, analysis and sharing ofinformation abouthealth conditions, risks
andresourcesmacommunity. Theassessmentfunctionisneededtoidentifytrendsmillness ,injuryanddeath
and the factors which may cause these events. It is needed to identify available health resources and their
application, unmet needs, and community perceptions about health issues.
Through the assessment function, a series of questions are addressed:
* What are the major health problems?
* What population groups are at risk?
* How are risks distributed geographically?
* What services are available?
* What is the quality of available services?
* Are health resources adequate?
* What do citizens perceive to be health concerns?
* What do providers perceive to be community health issues?
Assessment results are then shared with the community, policy makers and the health care community for
the purpose of developing resources and health policies to solve community health issues.
State Role
In most instances the state is responsible for establishing and maintaining surveillance systems, collecting
and assembling health status and utilization information, and performing analysis. Expertise is needed at the
state level forcomparative analysis and forecastingregional and state trends. The state department of health
also needs the capacity to provide technical assistance to local health departments for local forecasting and
interpretation of data.
Finally ,the state tofheathprovidesleade<s hipmcommunicatingabouthealthisscesandconcernswith
the public, generates public awareness through the news media, and issues state health reports.
Local Role
Local health departments are responsible for serving as collectors of the local data needed for their own
services and by the state to assemble a picture of the health status of their jurisdiction's citizens. In addition
to data, local health departments assess citizens' perceptions of community health status, or what people
believe to be the most important health issues facing their community.
Local health departments perform health resource inventories, hold public forms, conduct polls, collect
information from private and non -profit providers, and engage in research.
With the assistance of the state, local health deparanents provide local interpretations andfarecastsofhealthstatus
and other related information, and serve as the repository of such information for the junsdictim served.
Local health departments provide leadership at the local level in disseminating information to the public on
community health status. It is their responsibility to provide information directly to the news media and
community officials, and to publish easily understood reports.
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The Process
The policy development process uses:
• Scientific information
• Data from the assessment process
• Information from concerned citizens & providers
Concepts of political & organizational feasibility
• Community values
• An open process, involving all private & public
sectors by communicating, networking, &
building constituencies
The policy development process:
• Defines health needs
` Sets priority health issues by analyzing the
outcome of assessment
` Develops policies & plans to address the most
important health needs by setting goals &
objectives with measurable outcomes
' Develops alternative strategies for implementing plans
• Identifies necessary & available resources
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— — — — — — — — — — — -
- — — — — — — — — — — -
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Information gathered from assessment activities is used to develop local and state health policies. Policy
development includes consideration of political, organizational and community values. Good public policy
development includes information sharing, citizen participation, compromise and consensus building. The
process nurtures shared ownership of the policy decisions. Policy makers review the recommendations and
decide what will be done.
State Role
The State plays several roles in policy development. The state department of health is responsible for assem-
bling and providing a periodic state health report, identifying statewide priorities and goals which reflect a
series of local community planning efforts.
In partnership with local public health agencies, the State initiates and/or develops policies on health issues
that require statewide action or standards (e.g. clean air, water quality, tobacco control).
The state department of health should also serve as a clearinghouse for the State Executive Branch, taking a
leadership role in health policy and collaborating with other state agencies where overlapping responsibilities
exist.
Local Role
Many health policy issues first develop at the local level. Regional or state policy development efforts ought
to occur only when local leaders agree that such centralized policy development is more efficient and effec-
tive, and then only with active participation of local communities.
This approach is based on the assumption that the strongest public health policy is developed and owned by
citizens at the local level.
Local health departments should provide a leadership role in developing local priorities and plans in partner-
ship with the entire community. Local health departments should also have the authority to initiate, develop
and draft local ordinances or rules for health - related issues requiring a specific local response.
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Making sure necessary
resources are available
The assurance function calls upon
public health agencies to:
Provide public health nursing services
Provide environmental health services
Encourage, purchase or provide additional
population -based services
• Personal preventive services through private
& public providers
• improved access to care for individuals & families.
e.g. promoting bilingual and multicultural services,
addressing transportation, etc.
• Health promotion & education programs,
comprehensive school health education,
public education campaigns, worksite health
promotion
Maintain emergency response capacity
* Disease outbreaks
* Toxic spills
• Food and pharmaceutical recall
* Emergency systems
* Natural disasters
Administer quality assurance
• Health professional licensing & discipline
• Facilities licensing
• Public health services monitoring
• Enforcement of standards & laws
Help recruit & retain health care practitioners
Maintain administrative capacity
• Personnel
• Contracting
• Budgeting & accounting
• Legal counsel
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Assurance means making sure that needed health services and functions are available. Assurance focuses
on maintaining the capacity of public health agencies to manage day - today operations and provide the core
public health functions. Part of that capacity includes the ability to respond to critical situations and
emergencies, such as disease outbreaks, toxic spills or product recalls.
The assurance function also requires monitoring the quality of health services provided in both public and
private sectors. Population -based health protection and health promotion services are most often provided
directly by public health agencies, as are quality assurance activities.
While it is the responsibility of government health agencies to assure that necessary health resources are
available, the actual provision of health services can come from a variety of sources: private practitioners,
non -profit agencies such as community health centers and health maintenance organizations, and public
healthagencies.
State Role
The state department of health needs adequate legal authority, resources and trained leadership and staff to
provide a range of services, including maintenance of emergency response capacity at the state level,
enforcement of standards and laws, andmaintenance ofquality assurance in the service delivery system. The
state must also assure that there is adequate provision of the core functions throughout the state.
Local Role
Local health departments need the capacity to advocate, serve as catalysts for, coordinate and organize
responses to priority needs in the communities served Local health departments also need the capacity to
respond to majorregionalorlocalemergencies , enforce regulations, andprovideessentialoutreachfunctions,
including transportation and foreign language assistance, to assure that people experiencing barriers to
getting necessary health care services have access to the service delivery system.
Incases where no other resources are available in the community, local health departments need the capacity
to purchase or provide directly those personal health care services identified locally as priorities.
Finally, local health departments and/or other community organizations need the capacity to provide
population- basedhealthpromotion, healthpro= donandpreventivehealth services totirecommunity. Such
efforts are crucial if costs of the overall system are to be contained
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Thepurposeof adequatelyfunding thecore govemmentpublichealthfunctions is to achieveahealthierlife
span for all U.S. residents, regardless of ethnic or socioeconomic status. The following are preliminary
suggestions for organizing and funding the system
Sttudure
State and local public health officials recognize the need to adequately support an official government
structure with the capacity to deliver the core public health functions. This structure must include
coordination between state and local public health agencies.
Under this structure, local health departments conduct assessment and assurance activities, and develop
policy recommendations based on their findings. The state department of health routinely considers policy
recommendations, and reviews state -level assessment and assurance activities at least biennially. Based on
tbisregularreview, state andlocalpolicy makers will determine the actual percentage ofhealth funds needed
for the core government public health functions.
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Unfortunately, the amount currently being spent on core functions is inadequate. As was stated earlier, most
funding.is currently spent on the assurance function. Assessment and policy development are neglected In
order to adequately fund the core functions, six percent of total health care expenditures must be set aside
for this purpose. The six percent does not include payment for services to individuals who are insured by
a third party.
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Toachievethedesiredamountofsixpercentoftotalhealthcareexpenditures, acombinationofsources should
be tapped An increase in federal, state and local tax support is one possibility. Permits, licenses and fees is
for services could also be part of the total funding equation. Public health officials at the federal, state, and
local levels should all be involved in determining how to fund population -based services.
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The debate surrounding the strengthening of core public health functions will continue as the nation's health
caresystemisundergoingreform. NACHOurgesitsmembershiptobecomemvolvedinthisdialogueatloc aL
state and national levels. A healthier nation will be realized only when communities are afforded the
protections that public health agencies offer. Population based services must be specifically supported in
order to be truly effective.
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Healthy Communities: New Partnerships
for the Future of Public Health
Michael A. Stoto, Cynthia Abel, and:Anne Dievler, Editors
A Report of the First Year of the
Committee on Public Health
INSTITUTE OF MEDICINE
NATIONAL ACADEMY PRESS
i
Washington, D.C. 1996
Viii
REFERENCES
APPENDIX A
APPENDIX B
APPENDIX C
E,
HEALTHY COMMUNITIES
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Executive Summary
The Future of Public Health, issued in 1988, set forth a vision of public health
and a specific role for the governmental public health agency within that vision,
including the mission and content of public health, and an organizational
framework. In the eight years since the report was released, there has been a
significant strengthening of practice in governmental public health agencies and
other settings. Substantial social, demographic, and technological changes in
recent years, however, have made it necessary to reexamine governmental public
health agencies' efforts to improve the public's health. Drawing on the activities
and discussions initiated by the Institute of Medicine (IOM) Committee on Public
Health, the current report addresses two critical public health issues that can
greatly influence the opportunity for our public to be healthy as the United States
enters a new century--(1) the relationship between public health agencies and
managed care organizations, and (2) the role of the public health agency in the
community-wand their implications for the broader issues raised in The Future of
Public Health.
The committee's analysis, presented in this report, reaffirmed the
understanding of public health professionals and health scientists that the public's
health depends on the interaction of many factors; thus, the health of a
community is a shared responsibility of many entities, organizations, and
interests in the community, Including health service delivery organizations,
public health agencies, other public and private entities, and the people of a
community. Within this context of shared responsibility, specific entities
should identify, and be held accountable for, the actions they can take to
contribute toward the community's health. As a result of this understanding, o4
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HEALTHY COMMUNITIES
the committee focused its report on how governmental public health agencies,
especially at the state and local level, can develop partnerships with managed care
organizations for the delivery of personal and population -based health services and
with public and private community organizations to deal with broader concerns to
advance the health of the community. Developing these partnerships, the
committee believes, will be critical for advancing the health of the public and of
communities in the future.
PUBLIC HEALTH AND MANAGED CARE
There has been substantial growth in organized health care delivery systems
(which include managed care organizations) in recent years, and these
developments have important implications for the health of the public. Managed
care organizations are systems that are under the management of a single entity
that (a) insures members, (b) furnishes covered benefits through a defined network
of participating providers, and (c) manages the health care practices of
participating providers. In the discussions initiated by the Public Health
Committee, proponents of managed care have argued that its goals and tools are
consistent with public health. Many public health professionals, on the other hand,
have also expressed concerns about managed care organizations' motives and
ability to deliver on their promises. The committee's view, as developed in this
section, is that if the proper kinds of partnerships between managed care
organizations and governmental public health departments are developed,
managed care can indeed make an important contribution to improving the health
of the public.
The proliferation of organized health care delivery systems, which continue to
provide care for an increasing number of Americans, has made it possible in some
locales for governmental public health agencies to assure the provision of personal
health services (which involve a one - to-one interaction between patient and
provider) entirely within the private sector. How many elements of public health
services private organizations can or should subsume remains unclear, but the
number could be considerable. Providing care for the uninsured, however,
remains a challenge; govemmental public health. departments will be ill prepared
and inadequately funded to do so if no other personal services are being provided.
In order to ensure that partnerships between governmental public health
agencies and managed care organizations work effectively toward improving the
health of the public, the committee reiterates The Future of Public Health
recommendation that the function of local public health agencies should include
an "assurance that high - quality services, including personal health services,
needed for the protection of public health in the community are available and
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EXECUTIVE SUMMARY
accessible to all persons...:' This assurance function can be carried out "by
encouraging other entities (private or public sector), by requiring such actions
through regulation, or by providing services directly." Public health agencies can
only exercise this responsibility if they are adequately staffed, equipped, and
funded for this complex and demanding task and have appropriate relationships
with health service providers. These activities should not be undertaken at the
expense of existing essential public health services. Particular concerns arise when
health departments have a dual role: direct provision of personal health services to
some people and regulating private entities providing similar services to others.
To improve the efficiency of all health systems, health agencies and organized
health delivery systems, in conjunction with other community stakeholders,
most reach agreement on their proper roles and responsibilities, which will
vary by locale. Successful models of the integration of public health and
managed care and of joint approaches to policy development do exist and need to
be studied and tested more broadly,
Most public health agencies do not currently have the full statutory and
regulatory authority to ensure the accountability of the organized health delivery
systems to the public. In the current regulatory structure, health care delivery
systems are often regulated by insurance commissions that focus on fiscal integrity
rather than on health. State Medicaid agencies, usually separate from public health
departments, also typically focus on fiscal rather than medical accountability
dimensions, except in states that have a quality initiative. Recognizing the clear
need for financial oversight, governmental public health agencies should
increase their ability to oversee health care providers, with the goal of
becoming coequal partners with Insurance regulators and state Medicaid
agencies, to ensure that the public's health is addressed in the regulation of
public and private health care delivery systems. In many states, additional
legislative authority will be needed before public health agencies can take on this
role. This approach requires population -based health outcome and performance
standards that can be monitored, and public health agencies should be a major
contributor to the development and monitoring of these standards.
The functions described in this report cannot be undertaken without properly
trained professionals available to all communities. Thus, public health
professionals should be trained to work with health services organizations to
ensure quality personal health services In a community, as an essential
element in providing for the health of the public. In addition, public health
agencies should actively participate with organizations such as state health
professions boards, medical schools, and accrediting bodies in planning and
policy development.
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HEALTHY COMMUNITIES
PUBLIC HEALTH AND THE COMMUNITY
In its discussions with community group representatives and public health
officials, the committee heard of many innovative and effective approaches to
community partnerships and collaboration that are consistent with widespread
themes regarding community development and "reinventing government."
Broader application and further development of these new approaches to
collaboration within government (with legislators, boards of health, and nonhealth
agencies) and with community partners to achieve public health goals should be
encouraged
Shared responsibility, however, requires careful management. The
governmental.public health agency in each community needs to be capable of
identifying and working with all of the entities that influence a community's
health, especially those that are not directly health related. This function
must be undertaken by public health agencies that understand the
interactions of the full range of factors that influence the community's health.
To address this, a companion IOM report proposes a "community health
improvement process" that draws on performance monitoring concepts, an
understanding of community development, and the role of public health consistent
with the Committee on Public Health's discussions (IOM, in press). Public health
professionals who must work with a community to improve its own health
need to be trained and their roles need to be upgraded or enhanced.
The committee's discussions showed that many functions essential to the
public's health, such as immunizations and health education, can and are
being performed by either public or private entities, depending on the
historical context, community resources, and political dynamics of a
particular area. Some functions, however, such as environmental regulation
and enforcement of public health laws, must remain the responsibility of
governmental public health agencies. There also needs to be a resource in each
community to ensure that the health impact of multiple interventions in the
community are understood and addressed. This remains an ideal function for
governmental public health agencies and should not be delegated. Thus, the
committee reasserts the critical findings of The Future of Public Health that
governmental public health .agencies 'have a unique function in the
community: "to see to It that vital elements are in place and that the [public
health) mission is adequately addressed:' These elements include, assessment,
policy development, and assurance. For a governmental agency to execute this
responsibility effectively, there must be explicit legal authority, as well as health
goals and functions, that the public understands and demands. A fundamental
building block for this new approach to governance is public trust. With trust in
public institutions at risk or at low levels in many communities, governmental
EXECUTIVE SUMMARY
public health agencies must find ways to improve their openness and their
communication with the public to maintain and increase their trustworthiness.
REVISITING THE FUTURE OF PUBLIC HEALTH
Through its analysis of the interactions between managed care organizations
and governmental public health agencies and the role of public health agencies to
enhance the health of the community, and through its discussions about the many
responses to The Future of Public Health, the committee found that the constructs
of the mission and substance for public health agencies envisioned in that report
have been extraordinarily useful in revitalizing the infrastructure and rebuilding
the system of public health at all levels of government in the United States and
continue to be viewed as the fundamental building blocks for the future. However,
although clear progress has been made, some of the recommendations of that
report have not yet been implemented In light of this, the committee's analysis
shows that the concepts in The Future of Public Health remain vital and
essential to current and future efforts to energize and focus the efforts of
public health. These concepts need to be advanced, applied, and taught to all
health professionals.
The committee also found that the concepts of assessment, policy
development, and assurance, while useful in the public health community itself,
have been difficult to translate into effective messages for key stakeholders,
including elected officials and community groups. These concepts need to be
translated into a vernacular that these groups can understand.
In conclusion, the committee found that the public health enterprise in the
United States, as embodied in governmental public health agencies, is necessarily
diverse in organization and function, but operates within the common framework
set out in The Future of Public Health. The committee's discussions, however,
revealed continuing evidence of inadequate support for governmental public health
agencies in many communities. Now, as nearly a decade before, society must
reinvest in governmental public health agencies, with resources,
commitments, and contributions from government, private and non -profit
sectors, and substantial legal authorities, if the public's health is to improve.
The partnerships that are the focus of this report— between governmental public
health agencies and managed care organizations, and between public health and
the community—can provide both political - support and a vehicle for this
reinvestment.
• • t
Introduction
,o
Ae Future of Public Health set forth a vision for the public's health and the
specific role for the governmental public health agency in that vision, including the
mission and substance of public health and an organizational framework. In this
perspective, the public's health is a societal priority and goal, to be achieved by
governmental public health agencies and other public and private entities in the
community. Public health is also a perspective and a profession, both of which
focus on improving the health of the public.
Specifically, The Future of Public Health stated that the mission of public
health agencies is "fulfilling society's interest in assuring conditions in which
people can be healthy. Its aim is to generate organized community effort 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 vital
elements are in place and that the mission is adequately addressed." The Future of
Public Health expressed the basic governmental responsibility for the people's
health as assuring a substantive core of activities, assuring adequacy of means and
methods, establishing objectives, and providing guarantees in an ideal health
system, the substance of basic services will entail adequate personal health care for
all members of the community, education of the community-at- large, the control
of communicable disease, and the control of environmental hazards -biological,
chemical, social, and physical (IOM, 1988).
00
HEALTHY COMMUNITIES
The report defined the three core functions of public health as:
1. Assessment "Every public health agency [should] regularly and
systematically collect, assemble, analyze, and make available information on the
health of the community, including statistics on health status, community health
needs, and epidemiologic and other studies of health problems. Not every agency
is large enough to conduct these activities directly; intergovernmental and
interagency cooperation is essential. Nevertheless each agency bears the
responsibility for seeing that the assessment function is fulfilled. This basic
function of public health cannot be delegated."
2. Policy development "Every public health agency [should] exercise its
responsibility to serve the public interest in the development of comprehensive
public health policies by promoting use of the scientific. knowledge base in
decision - making about public health and by leading in developing public health
policy. Agencies must take a strategic approach, developed on the basis of a
positive appreciation for the democratic political process."
3. Assurance — "Public health agencies [should] assure their constituents that
services necessary to achieve agreed upon goals are provided, by either
encouraging actions by other entities (private or public sector), by requiring such
action through regulation, or by providing services directly.... Public health
agencies should] involve key policymakers and the general public in determining
a set of high - priority personal and communitywide health services that
governments will guarantee to every member of the community. This guarantee
should include subsidization or direct provision of high - priority personal health
services for those unable to afford them" (IOM, 1988).
In the eight years since this report was released, there has been a significant
strengthening of practice in governmental public health agencies and other
settings. Substantial social, demographic, and technological changes in recent
years (Brownson and Kreuter, in press), however, have made it necessary to
reexamine governmental- public health agencies' efforts to improve the public's
health.
Building upon the conc6pts of assessment, assurance, and policy development
contained in The Future of Public Health, a group of leading public health
organizations (Public Health Functions Steering Committee, 1994) adopted a
1 Members of the Public Health Functions Steering Committee include: American
Public Health Association; Association of State and Territorial Health Officials; National
Association of County and City Health Officials; Institute of Medicine, National
Academy of Sciences; Association of Schools of Public Health; Public Health
Foundation; National Association of State Alcohol and Drug Abuse Directors; and the
0 9
INTRODUCTION 9
vision of public health as "healthy people in healthy communities," six public
health goals, and ten essential public health services. The six public health goals
are to: (1) prevent epidemics and the spread of disease, (2) protect against
environmental hazards, (3) prevent injuries, (4) promote and encourage healthy
behaviors, (5) respond to disasters and assist communities in recovery, and (6)
assure the quality and accessibility of health services.
The ten essential public health services are to:
1. monitor health status to identify community health problems;
2. diagnose and investigate health problems and health hazards in the
community;
3. inform, educate, and empower people about health issues;
4. mobilize community partnerships to identify and solve health problems;
5. develop policies and plans that support individual and community health
efforts;
6. enforce laws and regulations that protect health and ensure safety;
7. link people to needed personal health services and ensure the provision of
health care when it is otherwise unavailable;
S. ensure the availability of a competent public health and personal health
care workforce;
9. evaluate , effectiveness, accessibility, and quality of personal and
population -based health services; and
10. research new insights and innovative solutions to health problems.
These essential public health services were used to describe public health more
readily to external audiences and constituencies and played an important role in
defining public health during the 1993 -1994 health care reform debate (Turnock
and Handler, 1995).
FACTORS AFFECTING PUBLIC HEALTH
We live in a complexly, interconnected global society in which there are
many threats to, and opportunities to improve, the public's health. In recent years,
we have witnessed the emergence or reemergence of infectious diseases such as
hanta virus, cryptosporidiosis, Fscherichia coli 0157, and Ebola virus (Gordon et
U.S. Public Health Service (Centers for Disease Control and Prevention, Health
Resources and Services Administration, Office of the Assistant Secretary for Health,
Substance Abuse and Mental Health Services Administration, Agency for Health Care
Policy and Research, Indian Health Services, and Food and Drug Administration).
0 N
N
10 HEALTHY COMMUNITIES INTRODUCTION
al., 1996). In the late 1980s and early 1990s, tuberculosis made a comeback in
cities across the United States, with many drug - resistant cases arising (OTA, 1993;
Gittler, 1994), and outbreaks of childhood diseases such as measles and mumps
appeared among poor inner city children (Atkinson et al., 1992; Kelley et al.,
1993; Vivier et al., 1994). The number of human immunodeficiency vines/
acquired immunodeficiency syndrome (HIV/AIDS) cases has surpassed 500,000
in the United States, and among persons aged 25--44 years, HIV infection is the
leading cause of death in men and the third - leading cause in women (CDC,
1995a).
Despite these outbreaks, which remain important, the 20th century has seen a
shift in the major causes of death , from infectious to chronic diseases, and
behavioral risk factors have increased in importance. Behavior - related factors
such as use of tobacco, alcohol, illicit drugs, firearms, and motor vehicles, as well
as diet, activity patterns, and sexual behavior, are responsible for nearly half of the
deaths in the United States and substantial amounts of disability (McGinnis and
Foege, 1993). Reflecting these realities, behavior and lifestyle interventions are
highlighted, for instance, in Healthy People 2000. National Health Promotion
and Disease Prevention Objectives (DHHS, 1991), with attention paid not only to
the behaviors themselves but also to lifestyle more generally and to the context and
social circumstances that influence individual behavior.
Consistent with the development of these trends, public health professionals
have come to realize that health is a dynamic state that is influenced by many
internal and external process, and that embraces well - being — physical, mental, and
emotional health. For both individuals and populations, health improvement
depends not only on medical care but also on other factors including individual
behavior, genetic makeup, and social and economic conditions for individuals and
communities. The Field Model, as described by Evans and Stoddart (1994),
presents these multiple determinants of health in a dynamic relationship. A wide
range of actors, many of whose roles are not within. the traditional domain of
health activities, have an effect on and a stake in a community 's health (Patrick
and Wickizer, 1995). Tl}e Field Model suggests a variety of public and private
entities in the community that, through their actions, could influence the
community's health. As communities try to address their health issues in a
comprehensive manner, everyone involved will need to sort out their roles and
responsibilities. They also should participate in the process of "community-wide
social change" that is needed to improve health (Green and Kreuter, 1990).
As the public health community was coming to appreciate these ideas about
the root determinants of health, other concerns about the high and rising costs of
health care, the lack of geographical and economic access to health services for
many, and questions about the quality and timeliness of the care provided led to
many governmental and private attempts to alter the organization, delivery, and
11
funding of health care. Foremost among these attempts in the past decade has
been the growth in organized health care delivery systems, including managed
care, and the size of the organizations that deliver it (Gabel et al., 1994; Robinson,
1996). However, the implications of these changes in the mode of service delivery
and funding for public health agencies are uncertain. Has access for disadvantaged
Populations improved or worsened? Can public health agencies delegate or
contract their clinical health promotion and disease prevention and control
programs to emerging health care organizations? If they can, can the quality and
effectiveness of such programs be assured? Is ensurigg adequate clinical health
care for all an important public health priority?,
As the health system has changed, so too has the political landscape. Although
Americans have been skeptical of government since the founding of this country,
in recent years there has been a growing mistrust of government, government
institutions, and politics (Dionne, 1991; La Porte and Metlay, 1996; Washington
Post, 1996). Although distrust of government has received considerable attention,
trust in other institutions such as the press, religious institutions, banking, and
business has also been challenged. Related to this lack of confidence in
government, or perhaps in response to it is a decided shift in responsibility from
the federal government to state and local levels. Furthermore, there has been a
growing movement to "reinvent government," including making it more
decentralized, responsive to clients or "customers," community-oriented, and
entrepreneurial by employing performance monitoring and outcomes standards
(Osborne and Gaebler, 1992). In many communities, public health functions
previously performed directly by government employees are being carried out by
employees of private organizations. As a result, the opportunities for public -
private partnerships are greater than ever before.
SUMMARY AND ORGANIZATION OF THIS REPORT
In summary, the discussions initiated by the Committee on Public Health have
suggested that three key forces shaping public health are (1) the rise of organized
health care delivery systems, including managed care; (2) the changing role and
public expectations of government; and (3) the increasing involvement and
mobilization of communities in matters pertaining to their own health. Drawing
on the committee's activities and discussions, this report addresses two critical
public health issues in the United States as it enters a new century—the
relationship between public health and managed care, and the role of the public
health agency in the community—and their implications for the broader
infrastructure and capacity issues raised in The Future ojPublic Health.
00
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12 HEALTHY COMMUNITIES
The committee's analysis, presented in this report, reaffirmed the
understanding of public health professionals and health scientists that the public's
health depends on the interaction of many factors; thus, the health of a
community is a shared responsibility of many entities, organizations, and
Interests in the community, Including health service delivery organizations,
public health agencies, other public and private entities, and the people of a
community. Within this context of shared responsibility, specific entities
should identify, and be held accountable for, the actions they can take to
contribute toward the community's health. As a result of this understanding,
the committee focused its report on how governmental public health agencies,
especially at the state and local levels, can develop partnerships with managed care
organizations to deliver personal and population -based health services and with
public and private community organizations to deal with broader concerns to
advance the health of the community. Developing these partnerships, the
committee believes, will be critical for advancing the health of the public and of
communities in the future.
•
Public Health and Managed Care
In the past decade, there has been substantial growth in organized health care
delivery systems in most parts of the United States. Managed care organizations,
the most common form of these systems, can be defined as "any system that is
under the management of a single entity that (1) insures members -- either by itself
or through an intermediary, (2) furnishes covered benefits through a defined
network of participating providers, and (3) manages the health cart practices of
participating providers" (Rosenbaum and Richards, 1996).
Public health practice is sometimes thought of as separate from, or
complementary to, the delivery of personal health services. A more helpful
distinction is between personal health services and community interventions.
Personal health services involve a one- to-one interaction between a provider and a
Patient (IOM, 1993). Personal health services are delivered primarily by private-
ssector organizations, but in many communities, governmental health dePartin ents
provide many of these services, especially for disadvantaged populations.
} Community interventions aim to alter the social or physical environment to
change one or more health- related behaviors or to directly reduce the risk of
causing a health problem. Community-based services are usually carried out by
public health agencies, other government agencies, or comm carried
voluntary
organizations. The provision of personal health services per se, even if they are
delivered in the community rather than in health care settings, is not a
community intervention. Outreach or community-based activities intended to
improve access to personal health services or their utilization, however, are
{ included. Public health .agencies are often challenged to provide both types of
services, but community organizations frequently help the public hea agency
13
ro
4%
0
14 HEALTHY COMMUNITIES
achieve a public health objective in a community (Box 1). Private health service
organizations sometimes sponsor outreach activities such as mass screening and
health fairs (at times with commercial interests), with and without a public health
agency's involvement.
BOX 1. Overcoming Barriers to Immunization: An Example for Public Health
In 1992 the 16,000 members of the Florida District of Kiwanis International formed
a partnership with the Department of Health and Rehabilitative Services' (HRS's) State
Health Office Immunization Program to help increase immunization levels in the
preschool population. As part of their "Young Children: Priority One" major initiative,
the Florida District Kiwanis made an eight -year commitment to be lead volunteer agency
assisting in implementing Florida's Immunization Action Plan. This plan provides
objectives to raise the immunization rates of Florida's two-year -olds to 900/* by the year
2000. At the time of the formation of the partnership, only 63% of Florida's two-year -
olds were up to date with their immunizations. Since the HRS- Kiwanis partnership was
formed four years ago, the immunization levels have increased by 2wo.
The Kiwanis have donated many thousands of volunteer hours in immunization
clinics and have organized coalitions, recruited other community groups, and purchased
computer equipment, vans, and educational materials. With the Kiwanis's help, Florida's
67 county public health units have increased their clinic hours, opened new clinic sites,
extended service times and added locat ions, arranged transportation services for low -
income clients, and coordinated services with other agencies to reach more children.
Because of this partnership, more of Florida's young children are protected against
vaccine - preventable diseases now than at any other time in the state's history. The 1995
Survey of Immunization Levels in the two-year -old population indicated that an
unprecedented 80% of Florida's two-year -olds are immunized. Much of the increase can
be attributed to the Kiwanis's leadership in volunteer efforts.
This partnership has helped reduce the dangers that exist when society fails to
immunize its children. For example, the number of measles cases in Florida. had nearly
doubled, from 322 cases in 1989 to 603 cases in 1990. Two of the cases occurred among
unvaccinated preschool children. In 1995, there were 14 confirmed measles cases in
Florida. Through this partnership, the Kiwanis, the county public health units, and the
immunization program office have set an example that demonstrates the positive benefits
that result when a community-based partnership works together to donate time, energy,
and resources to improve the health of Florida's children.
SOURCE: Based on information provided by Charles Mahan, Dean of the University of
South Florida College of Public Health (former director, Florida State Department of
Health and Rehabilitative Services). 1996.
PUBLIC HEALTH AND MANAGED CARE
15
An estimated 90 million insured Americans are enrolled in managed care
plans, including more than 25% of Medicaid beneficiaries and 10• /a of Medicare
beneficiaries (Rosenbaum and Richards, 1996). Most of the growth in enrollment
has occurred in recent years. Between 1988 and 1993, the percentage of
employees enrolled in a managed care plan increased from 290/a to 51% (Gabel et
al., 1994). In the Medicaid program, the growth has been even more dramatic as
states have requested waivers from the Health Care Financing Administration
(HCFA) to shift their Medicaid populations into managed care arrangements.
Between 1993 and 1994, the number of Medicaid beneficiaries in managed care
increased by 63 0/e, from 4.8 million to 7.8 million (Kaiser Commission, 1995). The
factors contributing to the growth in managed care are the rising costs of personal
health care and an interest among employers to find ways to control providers and,
therefore, to control costs (Rosenbaum and Richards, 1996). States have also used
managed care arrangements as a way of containing spiraling costs in the Medicaid
program and of trying to improve access to care (Kaiser Commission, 1995).
STRENGTHS AND WEAKNESSES OF
MANAGED CARE FOR PUBLIC HEALTH
Managed care offers opportunities for public health (CDC and GHAA, n.d.;
Baker et al., 1994; HRSA, n.d.) but it also poses challenges. In the discussions
initiated by the Public Health Committee, proponents of managed care have
argued that its goals and tools are consistent with public health. Many public
health professionals, on the other hand, have also indicated concern about
managed care organizations' motives and ability to deliver on their promises. The
committee's view, as developed in this section, is that .if the proper kinds of
partnerships between managed care organizations and governmental public health
departments are developed, managed care can indeed make an important
contribution to improving the health of the public.
Accountability, Responsibility, and Quality
Because it is responsible for delivering care to a defined group of enrollees,
managed care makes possible, for the first time, accountability in terms of quality
of care for populations, including access to care and health outcomes. This is
possible because managed care organizations can monitor the health outcomes of
enrollees and examine their use of services. However, this is not regularly done.
Some managed care organizations, especially large staff -model managed care
organizations, are using their data systems to track the health of their enrollees, but
ce
to
16 HEALTHY COMMUNITIES
many managed care organizations do not collect the types of information needed
for surveillance and epidemiologic studies. There have been a number of attempts
to assess the quality of care offered by managed care organizations. The National
Committee for Quality Assurance (NCQA), which accredits managed care
organizations, has developed the Health Plan Employer Data and Information Set
( HEDIS), a set of performance measures for managed care organizations designed
to meet employers' and government purchasers' needs for information about the
value of services they purchase and to systematize the measurement process
(NCQA, 1993).
The data systems maintained by some managed care organizations are an
important tool for improving performance and maintaining accountability, and
simply by having performance monitoring systems, these organizations compare
favorably with fee - for - service delivery systems or indemnity insurance companies
that typically have no data with which to monitor performance. The committee
heard of instances in which a managed care organization's performance --in terms
of provision of preventive services, for example —was criticized based on the
organization's own data, with the implicit assumption that other providers do
better. Such assumptions may well be incorrect and are unfair because they cannot
be checked unless the other providers have appropriate data systems. Experience
suggests that performance monitoring as a basis for punishing those who are not
producing as expected is not an effective way to alter behavior and improve
outcomes. Rather, performance monitoring should be used to encourage
productive action and broad collaboration (Berwick, 1989; IOM, in press).
Population Orientation and Prevention
Managed care's responsibility for a defined population -gives it an interest in
promoting health and preventing disease in that population, which is the mission of
public health. Both managed care organizations and governmental public health
agencies have a philosophical emphasis on promoting health and preventing
disease. Both address prevention and health promotion in a defined population.
However, in actual practice, some managed care organizations seem more
concerned about efficiency and controlling short run costs than about prevention
or the health status of their members. Governmental public health agencies have a
geographic perspective and are accountable to the people within their jurisdiction
while many managed care organizations focus on their current enrollees, an ever -
changing group, who may only be a subset of the population. Committee
discussions suggested that in the long term, it is important for managed care
organizations to think more broadly and to promote health in the whole
community because anyone may be their enrollee in the future (Box 2). In a
PUBLIC HEALTHAND MANAGED CARE 17
capitated system with limited turnover, some prevention activities might result in
larger future profit margins. Unlike public. health agencies, managed care
organizations are primarily accountable to purchasers, subscribing employers,
large groups of payers, and ultimately their stockholders or trustees. As managed
care organizations respond to public demands for accountability, more should find
ways to measure the quality of services they provide. A focus on health outcomes
and prevention objectives, as some organizations which have adopted HEDIS and
other performance measures have done, would help.
BOX 2. Group Health Cooperative of Puget Sound
Group Health Cooperative of Puget Sound is a large, nonprofit health maintenance
organization (HMO) that was established in 1947. It has approximately 540,000
enrollees, of whom about 80,000-90,000 are enrolled in the Medicare and Medicaid
Basic Health Plan. The cooperative has been involved in community -based health for
more than 50 years. Its public health focus grew out of 10 years of involvement with
public health in community issues and priorities such as AIDS prevention.
In 1992, Group Health adopted a vision statement that calls for delivery of quality
health care to the whole community, not just its enrolled population. They also adopted
a set of community service principles to recognize the work that Group Health had been
doing in the community in the area of health promotion and disease prevention. They
currently focus their attention on four areas: (1) childhood immunization, (2) the
reduction of infant mortality, (3) health care for homeless families, and (4) the reduction
and prevention of interpersonal violence. In their community -based programs, Group
Health has gone beyond just providing immunization and preventive clinical services to
issues that deal with changing social norms, such as violence and alcohol abuse. Group
Health is also working with the State of Washington on surveillance issues to improve
their performance measurements and develop more integrated information systems.
Group Health considered several factors in implementing its community programs.
Improving community health in general is expected to lead to improved health for the
members of Group Health as well. Involvement in community -based programs also
helps Group Health compete for contracts with large employer groups and with Medicaid
and Medicare populations. In addition, community service programs help to encourage
innovative approaches to providing services to the patient population.
SOURCE: Based on a presentation by William Berry, director, Center for Health
Promotion, Group Health Cooperative of Puget Sound, at the February 22, 1996,
meeting of the Public Health Committee.
co
Ch
18 0
HEALTHYCOMMUNITIES 0
Personal Health Services for Vulnerable Populations
As managed care organizations enroll increasing numbers of people from
disadvantaged groups, the biggest challenge for public health agencies is in the
area of providing personal health services for poor and vulnerable populations.
Public health agencies, primarily at the local level, have played an important role
in providing health care services to both Medicaid - eligible and uninsured and
underinsured population groups. For example, they provide maternal and child
health services, sexually transmitted disease (STD) services, and tuberculosis
services. For certain services, issues of expertise or confidentiality would suggest
that public health agencies are the appropriate entities to continue to provide these
services (Frieden et al., 1995; IOM 1996), so local public health agencies must
maintain this capacity. As more states shift their Medicaid enrollees into managed
care, public health agencies have the option of trying to obtain contracts with
managed care organizations, but many are ill- equipped to compete for and
negotiate with health plans (Lipson and Naierman, 1996). Many issues of
language, culture, tradition, class, race, and ethnicity need to be taken into account
when providing services to especially vulnerable populations. Perhaps the most
serious aspect of this problem is providing services to those who are covered by
neither insurance nor Medicaid and who are especially vulnerable.
As many cities and counties move to privatize public hospitals, which have
traditionally served vulnerable populations, they will have to consider whether and
how managed care organizations fill this role and how the delivery of care to the
underinsured and uninsured will continue. Individuals who are eligible for
Medicaid but unfamiliar with managed care organizations may not understand
how to access needed services. A strategy of partnering with both governmental,
public health agencies and community-based organizations, which have the skills
and experience needed to work effectively with these vulnerable populations,
could strengthen the entire health system's response to the needs of these special
populations.
Many state Medicaid agencies do not have the management skills to
monitor the performance of managed care organizations or to .write appropriate
contracts with these organizations (Box 3). Competitive cost - cutting pressures
coupled with vulnerable populations may result in opportunities for health care
plans or providers to take advantage of poor patients. The problem of turnover
of patient population as enrollees lose and regain their eligibility for Medicaid
also contributes to serious problems of continuity of care.
•
PUBLIC HEALTHAND MANAGED CARE 19
BOX 3. Medicaid Managed Care
The move toward managed care for Medicaid patients offers promise for improving
health outcomes and solving potential problems. The promise is due to the shift inherent
in managed care toward interest in the health of defined populations. This facilitates the
use of public health assessment tools (e.g., epidemiology), strategic thinking about
efficient ways to . improve the health of populations, and opportunities to undertake
activities focused on disease prevention.
Problems that may occur during this transition to Medicaid managed care include
(1) personal health services traditionally carried out by public. health departments (i.e.,
prenatal care, immunization services, family planning and sexually transmitted disease
[STD] clinics, and Early and Periodic Screening, Diagnosis, and Treatment [EPSDTI)
will not be completely transferred to a managed care organization; (2) poor people who
are eligible for Medicaid but are unfamiliar with managed care organizations may not
understand how to access needed service, (3) many state Medicaid agencies do not have
the management skills to monitorthe performance of managed care organizations or to
write appropriate contracts with them; and (4) competitive cost- cutting pressures coupled
with vulnerable populations and weak oversight may result in some unscrupulous health
care providers taking advantage of poor patients.
There is a growing realization that managed care organizations need the expertise
and authority of public health agencies to undertake community -based interventions and
perform outreach services that are necessary for maintaining the health of the populations
for which they are responsible. Public health services are also necessary in cases in
which confidentiality is an issue, such as at STD or family planning clinics.
Many public health professionals now provide ,personal health services, often in
community-based categorical public health clinics. Such services are the type that
managed care organizations should be able to handle, and therefore, once they are
trasferrred, there will be less of a need for health professionals with the same skills in
public health departments. There will be an increased need in both public health
departments and managed care organizations for people with public health assessment
skills and health care management skills.
L URCE: Presentations to the Institute of Medicine (IOM) Board on Health Promotion
Disease Prevention and the National Research CounciUlOM Board on Children and
ilies in joint session on June 15, 1995.
DEFINING ROLES AND RESPONSIBILITIES
Given the challenges involved in the transition to managed care, it will be
important for each community to define the roles and responsibilities of
governmental public health agencies and managed care organizations in improving
health. Depending on local conditions, public health agencies can play a variety of
roles, from serving in an advisory or regulatory capacity to obtaining contracts to
OD
V
20 HEALTHY COMMUNITIES
provide services. Managed care organizations can play a role in health promotion
and disease prevention, disease surveillance, and promoting quality. The IOM
report The Hidden Epidemic: Confronting Sexually Transmitted Diseases (1996),
illustrates the opportunities and problems in the relationship between health
department and managed care organizations in one area (Box 4). Two recent
reports (CDC and GHAA, n.d.; Joint Council, 1996) identify a variety of
approaches to collaboration. More generally, a new joint initiative of the
American Medical Association and the American Public Health Association is
exploring new ways that medicine and public health can collaborate to improve
health and health care in the United States (Reiser, 1996).
BOX 4. IOM Committee on the Prevention and Control of Sexually
Transmitted Diseases (STDs)
The Institute of Medicine (IOM) Committec on the Prevention and Control of STDs
held a workshop on November 9, 1995, to examine the role of managed care in STD
prevention and control. The national movement toward managed care coupled with
limited public funds for health programs will have a significant impact on the delivery of
services provided by public health agencies, especially those that involve many providers
and intervention points such as STD prevention and control.
There are many opportunities and challenges for managed care to address STD
issues effectively. Strengths of managed care organizations that are particularly
appropriate for this role include (1) a population -based focus (i.e., group and staff
models track disease and health trends for a population), (2) the ability to coordinate and
integrate STD services into primary care, and (3) accountability to purchasers of health
services.
Increasingly, managed care organizations are enrolling Medicaid populations whose
health care used to be provided by local public health departments. In some states,
Medicaid revenues have been a major source of funding for public health clinical
services. The absence of the revenues becomes a problem for local health departments as
well as for community-based health clinics that have been providing services.
Nevertheless, local health departments report that many persons with health insurance
continue to use public health clinics, local health department STD clinics, or other clinics
outside of their health plan for STD - related services.
SOURCE: Presentation by Richard Brown, member of the IOM Committee on the
Prevention and Control of STDs, at the February 22, 19%, meeting of the Public Health
Committee; IOM (1996).
PUBLIC HEALTH AND MANAGED CARE 21
Roles for Public Health Agencies
With their potentially extensive knowledge of the community and its depth
and breadth of experience in fields such as epidemiology and injury prevention,
governmental public health agencies can play an important role with managed care
organizations. The Future of Public Health's analysis implies that public health
departments should work with managed care organizations, in the public interest,
as part of their assessment and assurance mandate. "Their role can include
everything from offering advice about data and information systems, to developing
training and education programs, even to fostering an advocacy role (Box 5). In
Particular, governmental public health agencies can:
• provide information about the health status, risks, and determinants of
communities served by managed care organizations, which is vital for raising
awareness and setting priorities even if the jurisdictions of the health agencies do
not correspond exactly to the population covered by the managed care
organizations;
• participate with managed care organizations in planning and policy
development related to voluntary collaborative actions or regulatory policy
development;
• provide services, such as case management and enabling services, to
managed care clients; and
• assist managed care organizations with assurance and oversight when
working with state agencies with regulatory responsibility.
In carrying out the assessment function, governmental public health
agencies have a responsibility to monitor the health status of managed care
enrollees, just as for others in their communities. Similarly, governmental
agencies must ensure that members of managed care plans have access to quality
health care, and assessment results provide relevant information to carry out this
function. In conjunction with managed care, these two functions are clearly
interrelated and have undeniable costs. Managed care organizations can and
should participate in data preparation and analysis, and their data systems can
facilitate these activities. If there are to be independent checks on managed care
plans' performance, these functions must, at some level, involve public health or
other governmental agencies.
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89
Future Trends Affecting Public Health:
Challenges and Opportunities
Ross C. Brownson and Matthew W. Kreuter
Many accomplishments of public
health can be cited, yet public health
professionals face unprecedented
challenges and opportunities in the
coming decades. To assist public
health practitioners, researchers, and
educators in preparing for current and
future changes affecting the
population's health, the authors
describe several important "macro -
level" trends. These trends include:
the aging of the population, changing
patterns in the U.S. racial /ethnic
composition, changes in health care
delivery systems, the explosion of
information technologies, changing
needs in the public health work force,
the growth in health - related
partnerships, and anti- govenunent
sentiment and polarization. A series of
implications for each of the major
trends is provided. It may be
important for public health leaders
and policy makers to take these trends
and implications into account as they
plan and prioritize future approaches
to disease prevention and health
promotion.
Key words: demographic, health care, policies,
prevention
I Public Health Management Practice, 1997, 3(2), 48-60
0 1997 Aspen Publishers, Inc.
If you don't know where you are going, you might
wind up somewhere else.
—Yogi Berra
UBLIC HEALTH involves organized com-
munity efforts aimed at prevention of dis-
ease and promotion of health.' As illustrated
in Figure 1, health is a complex continuum
in which a variety of social and environmental fac-
tors determine individual well- being.' Public health
has traditionally taken a population -based approach
to disease prevention; whereas clinical medicine has
taken an individually oriented approach toward
treatment of disease. The Institute of Medicine de-
fined the core functions of public health as assess-
ment, policy development, and assurance.' Other
suggested core functions have included communica-
tion, training, and generation of new knowledge (Gil-
bert Omenn, personal communication, February 14,
1996) .3 These public health functions are addressed
by public agencies, private organizations, universi-
ties, and individuals .4
The philosophical basis for public health is the
application of scientific knowledge for social justice,
Ross C. Brownson, PhD, is Professor of Epidemiology and
Chair of the Department of Community Health at the
Saint Louis University School of Public Health, St. Louis,
Missouri.
Matthew W. Kreuter, PhD, MPH, is Assistant Professor
of Behavioral Science and Health Education,of the
Department of Community Health at the Saint Louis
University School of Public Health, St. Louis, Missouri.
The authors are grateful for the assistance from numerous experts
in public health who provided valuable insights on the issues:
Robert Harmon, Martha Katz, Coleen Kivlahan, Jeffrey Koplan,
James Marks, and Mr. Charlie Stokes were involved in key infor-
mant interviews; Barbara Arrington, John Bagby, Elizabeth Baker,
Sharon Homan, Richard Kurz, Jeffrey Mayer, Anthony Moulton,
Gilbert Omenn, and Ms. Linda Hillemann reviewed the initial
trends.
4P
50 JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE /MARCH 1997
Spiritual
Envilmment
Natural Sow
Environment Environment
Community
Government/ Built
Politics Genetics Medical Environment
20% Delivery
System
10%
Education Community
�/ R Safety
Lifestyle Environment
° 20% Arts/Culture/
Housing 0 Heritage &
Recreation
Transportation/
Mobility
Access to
Health Care
Economy/
Employment
Figure 1. Individual and community factors that influence health (Source: Daughters of Charity National Health
System; 1994).
including the concept of health as a human right.5.6
Public health is ultimately and essentially an ethical
enterprise committed to the notion that all persons
are entitled to protection from hazards and to min-
imization of risks of death and disability.' The or-
ganizational framework for public health involves
activities under the formal structures of government,
related efforts in private and voluntary agencies, and
the educational and research efforts of universities.
An innovation of U.S. efforts in public health is the
multidisciplinary approach to disease prevention.°
The accomplishments of public health and related
social changes have extensively changed the pattern
of death and disease in modern society. Infant mor-
tality in the United States has fallen from 150 per
1,000 live births in 1900 to 8.5 per 1,000 in 1992.9.10
Life expectancy from birth has risen from 47 years in
1900 to more than 76 years in 1992.10 This represents
an increase of over two days of life expectancy for
every week since the beginning of this century.
Much of the gain in life expectancy can be attributed
to provision of safe water and food, sewage disposal,
90
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control of infectious diseases through immunization,
and other population- based, public health activ-
ities." Despite the marked reductions in overall
mortality, disparities remain among certain sub -
populations in the United States (e.g., persons of low
socioeconomic status, African Americans).
We recently conducted a review of major trends
that are likely to affect public health in the coming
decades. The trends identified were those that were
already in progress and likely to have significant im-
pacts in the coming decades rather than those that
may be more speculative in nature. To identify these
trends, we conducted key informant interviews with
six experts in public health who represented a range
of perspectives including academia; medicine and
health care; and local, state, and federal governmen-
tal public health. Findings from these structured in-
terviews were summarized and subsequently re-
viewed by nine other public health experts. This
review was designed to validate major trends and to
assist in prioritizing the initial list of 88 "implica-
tions" that were identified in the first phase of the
review process. A literature review also was con-
ducted to help validate and clarify the implications
of major trends.
In this article, we summarize seven "macro- level"
trends, ranging from sociodemographic changes to
policy and social trends. For each, we provide evi-
dence of the trend and a discussion of its expected
impact on the public health system. The implica-
tions of each trend also are summarized for public
health research, practice, and education (see Appen-
dix).
Trend
Aging of the population.
Evidence
The elderly, defined as persons aged 65 years and
older, are the most rapidly growing segment of the
U.S. population. Among the elderly, the proportion
of persons aged 85 years and older is growing most
rapidly. In 1960, 9.2 percent of the population was
aged 65 years and older. This compares with 12.5
percent (31.2 million) in 1990.28 From 2010 to 2030,
the survivors of the "baby boom" cohort will enter
the elderly age groups. During this period, the popu-
lation aged 65 years and older is projected to in-
crease from 39.7 million in 2010 to 69.8 million in
Future Trends Affecting Public Health 51
2030.28 The 65 year and older age group is expected
to comprise over 20 percent of the nation's popula-
tion by 2030.28
Impact
The greater proportion of elderly persons will
place increasing demands on the public health and
health care systems. About 80 percent of the elderly
visit a doctor eight times a year or more because of
illness, and the elderly consume twice as much med-
ication as all other age groups combined .29 Older
adults are more likely to suffer from multiple chronic
diseases and therefore require more complex treat-
ment regimens and drug treatments .13 New methods
are needed to prevent and control a variety of
chronic diseases that afflict the elderly. This group of
diseases includes heart disease, stroke, cancers, ar-
thritis, osteoporosis, and Alzheimer's disease.30 In
addition to impacts in the elderly subgroup, the old-
est of the baby boom cohort are now turning 50,
which will impact a variety of preventive services.
Trend
Changing patterns in the U.S. racial /ethnic compo-
sition.
Evidence
The racial /ethnic composition of the United States
is projected to change substantially in the coming
decades. The non - Hispanic Caucasian population is
projected to grow slowly from 191 million in 1992 to
208 million in 2029, then slowly decline to 202 mil-
lion in 2050 (53 percent of the total population) .28
The African American population is projected to
double from 32 million in 1992 to 62 million in
2050.28 The Hispanic population is anticipated to
triple in size from 24 million in 1992 to 81 million in
2050.28 The Asian and Pacific Islander group is ex-
pected to continue as the most rapidly growing ra-
cial /ethnic group on a percentage basis — rising from
9 million in 1992 to 41 million in 2050.28 Each of
these major racial/ethnic groups is younger than the
non - Hispanic Caucasian population. For example,
76.5 percent of African Americans are under 45 years
of age, compared with 65.8 percent of non - Hispanic
Caucasians. Urban areas are likely to grow dispro-
portionately more diverse compared with other met-
ropolitan and rural areas of the United States.91
91
52 JOURNAL OF PUBLIC HEALTH MANACEtaw AND PRAcncE /MARCH 1997
Impact
As outlined in- Healthy People 2000, large health
disparities exist for certain racial/ethnic groups; par-
ticularly at high risk are African Americans and
American Indians /Alaska Natives .32 In addition, re-
cent data suggest erosion of gains in life expectancy
from earlier birth cohorts (e.g., among African
American males) .33 Unless the factors largely respon-
sible for health disparities (i.e., infant deaths, cardio-
vascular disease, cancer, homicide) are addressed
more fully, we can expect a leveling or decline in the
health status of the overall population.94 Because of
the shift in proportions of racial /ethnic groups noted
earlier, new health issues are likely to be encoun-
tered. Many of the current epidemics affecting
younger age groups in minority populations are
likely to continue and will need particular attention.
These include human immunodeficiency virus /ac-
quired immune deficiency syndrome transmission,
substance abuse, violence, conditions resulting from
the lack of prenatal care, control of sexually trans-
mitted diseases, and teen pregnancy. It is important
to note that although race is commonly cited as a risk
factor for poor health status, the underlying factor is
largely poverty.31
Trend
Changes in health care delivery systems.
Evidence
The United States spends more per capita on
health care than any other country in the world -14
percent of our gross domestic product in 1994.29 Of
the total health care budget, only about 3 percent is
allocated to prevention.3° Primarily due to concern
about rising costs, the health care system is currently
Primarily due to concern about rising
costs, the healthcare system is
currently undergoing profound
changes that will influence public
health and health care greatly in the
coming decade.
undergoing profound changes that will influence
public health and health care greatly in the coming
decade. Managed care organizations, specifically
health maintenance organizations, have grown from
enrollments of 6 million people in 1976 to 50 million
in 1994.37 Within the next decade, 80 to 90 percent of
the insured 'population will receive its health care
through various forms of managed care.'
Impact
The traditional governmental role in public
health of providing clinical, preventive services is
changing and is likely to evolve further. As
underserved populations are increasingly moved
into managed care settings, fewer health depart-
ments will provide services directly to clients.
Changes within the Medicaid and Medicare pro-
grams also are likely to influence prevention oppor-
tunities among vulnerable populations (i.e., persons
of low income, the elderly, and the disabled). At the
present time, there is little assessment of the effects
of these changes in health care coverage for
underserved populations; it is thus unclear whether
recent changes will have overall positive or nega-
tive effects on the health of the public.3e
In order for managed care companies to enhance
the overall health of the public, they will have to be
responsible for the communities they serve, in much
the same way public health departments have been
in the past. Because these companies will be paid on
a capitated basis, it will be in their best interest to
minimize disease and injury risks.39 To do this effec-
tively, it seems likely they will play a larger role in
the kinds of assessment, advocacy, and assurance
activities traditionally the bailiwick of public health
workers .2U13
It is unlikely that economic incentives alone will
be sufficient for consistent efforts in risk minimiza-
tion and increased service coverage when some pre-
ventive activities are long -term and effectiveness is
uncertain. Therefore, for private reform efforts to
succeed, public health must fully assume the as-
surance role by serving as a leader and catalyst in
providing those oversight functions that only gov-
ernment can perform.' Public health agencies can
provide a vital function in the managed care environ-
ment by providing external incentives —i.e., consis-
tent and timely feedback on health outcomes to pro-
viders of health care.
In conjunction with the changing health care sys-
tems, the demand for personnel in various medical
92
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disciplines will change &reatly over the coming de-
cade. It is likely that the growth of managed care will
amplify the oversupply of specialist and sub- special-
ist physicians .4.40 It will also magnify the need for
new educational competencies for physicians, in-
cluding a greater emphasis on population - based
sciences such as those taught in schools of public
health.'°
Trend
Explosion of information technologies.
Evidence
The proliferation of information technologies will
continue to provide exciting opportunities and new
approaches to public health and health care delivery.
It has been estimated that the amount of information
available to the public doubles every five years .29
The explosion in information technologies provides
new ways in which to make information -based deci-
sions—i.e., new and better methods of communica-
tion, improved analysis tools, and improvements in
presentation of knowledge .41 In the clinical setting,
information -based decision making may involve
electronic synthesis of complete patient histories,
literature review to support diagnosis and treatment
decisions, and computerized systems for prompting
physicians and patients, and for measuring quality
in the health care setting.42.49
Impact
Persons working in all areas of public health in-
cluding universities, state and local health depart-
ments, and health care settings will have an unprec-
edented array of information tools at their disposal.
However, it is important to note that improved tech-
nology does not necessarily result in improved and
integrated information." In many areas of public
health, information systems have been created that
cannot "talk" to each other, making their use less
than optimal.
Trend
Changing needs in the public health work force.
Evidence
Unlike professions such as medicine or law, no
single educational degree is required for professional
Future Trends Affecting Public Health 53
work in public health. The public health work force
is estimated at one half million, yet less than one
third of all employees in public health departments
have formal training in public health.43 As health
care reform proceeds at state and local levels, the
necessary skills for public health professionals are
likely to change and the boundaries between private
and governmental sectors in health become less dis-
tinct.
Impact
Public health is a rapidly changing discipline as
noted earlier in discussions about managed care and
changing demographics. Abilities. that are likely to
be needed in the coming decade include stronger
skills in community assessment, program evalua-
tion, better understanding of the uses of information
technologies, and stronger leadership skills.l,48 The
consequences of an undertrained work force will be
greater than in the past due to the rapidly changing
nature of public health.
Trend
Growth in health- related partnerships.
Evidence
Many of the changes noted earlier are likely to lead
to new opportunities for interdisciplinary partner-
ships that can link the academic and public health
practice settings. Several recent examples of such
partnerships are the "community empowerment"
projects funded by the Kellogg Foundation, large
community-based trials to reduce chronic disease
morbidity funded by NHLBI, and the Prevention Re-
search Centers funded by the Centers for Disease
Control and Prevention.47,48 Increasingly, researchers
are recognizing that the most effective community-
based research projects are those that involve a true
partnership between academics and community
groups."" Partnerships discussed earlier in this sec-
tion, such as those between traditional public health
agencies and managed care providers, are likely to
increase in frequency and scope.
Impact
The growth in community-based partnerships and
applied prevention research has the potential to
greatly inform the methods for long -term mainte-
nance of community interventions. Presently, there
93
54 JOURNAL OF PuBLic HEALTH MANAGm iENT AND PRAcncE /MARcH 1997
is little research on the "hows" and "whys" of effec-
tive academic - community collaboration.so
Trend
Anti- government sentiment and polarization.
Evidence
The current trend, particularly at the federal level,
is toward smaller government and lower taxes.
Trends over the past several decades indicate that
the U.S. population is increasingly dissatisfied with
government. Since the 1960s, the percentage of
Americans expressing trust in Washington has de-
creased from around 70 percent to near 20 percent si
The current movements toward decreasing the fed-
eral deficit and cutting taxes are likely to continue.
Similarly, the present trend of shifting many govern-
mental responsibilities in public health from the fed-
eral to state and local levels is likely to continue.
In addition to skepticism and distrust about gov-
ernment in general, the governmental role in public
health is poorly understood. Both focus group data
and population -based surveys suggest that despite
people's general knowledge of the importance of
care access, the scope and significance of public
health is not understood.0 Common misperceptions
include exclusive associations of public health with
health care to the poor, misplaced confidence that
governmental public health functions can be per-
formed by others, concern about the intrusiveness of
lifestyle messages, and resentment of public health's
regulatory role. 52
Impact
Current trends, in government will place increas-
ing stress on the resources available for public health
and health care. Funding may decline in several ar-
eas including Medicare, Medicaid, and Public
Health Service training grants. It is likely that re-
search funding from the federal government will re-
main relatively level, with declines in certain areas,
and that state public health agencies may have
greater latitude to make decisions about resource al-
location for public health.
■ ■ ■
Perhaps more so than at any other time in history,
public health currently faces unprecedented chal-
lenges and opportunities. In many respects the
threats and possibilities in the coming decades are
paradoxical. At the time when technological ad-
vances provide public health with more tools than
ever before, the political climate may make those ad-
vances more difficult to implement, evaluate, and
maintain. It is hoped that awareness of these chal-
lenges and addressing them within the context of the
trends presented in this article will benefit public
health professionals and the overall health of the
public.
REFERENCES
1. Institute of Medicine. The Future of Public Health. Washing-
ton, D.C.: National Academy Press, 1988.
2. Fielding, J., and Halfnn, N. "Where is the Health in Health
System Reform ?" Journal of the American Medical Associa-
tion 272 (1994): 1292 -1296.
3. The Johns Hopkins University School of Hygiene & Public
Health. MPH Alum. Baltimore, Md.: Master of Public Health
Program Office, December 1995.
4. Pew Health Professions Commission. Critical Challenges. Re-
vitalizing the Health Professions for the Twenty-First Century.
The Third Report of the Pew Health Professions Commission.
San Francisco, Calif.: University of California, San Francisco,
Center for the Health Professions, November 1995.
5. Foege, W.H. "Preventive Medicine and Public Health." Jour-
nal of the American Medical Association 270 (1993): 251-
252.
6. Susser, M. "Health as a Human Right: An Epidemiologist's
Perspective on the Public Health." American Journal of Pub-
lic Health 83 (1993): 418-426.
7. Beauchamp, D.E. "Public Health as Social Justice." Inquiry
13 (1976):3-14.
8. Susser, M. "The Bell Tolls for a School of Public Health —and
for Thee ?" American Journal of Public Health 83 (1993):
1524 -1525.
9. Taylor, W.R. et al. "Current Issues and Challenges in Chronic
Disease Control." In Chronic Disease Epidemiology and Con-
trol, edited by R.C. Brownson,' P.L. Remington, and J.R.
Davis. Washington, D.C.: American Public Health Associa-
tion, 1993.
10. National Center for Health Statistics. Health, United States,
1994. DHHS Pub. No. (PHS) 95 -1232. Hyattsville, Md.: Gov-
ernment Printing Office, 1995:
11. Centers for Disease Control and Prevention. Public Health in
the New American Health System. Discussion Paper. Atlanta,
Ga.: CDC, 1993.
12. Greenberg, B.G. "The Future of Epidemiology." Joumal of
Chronic Disease 36 (1983): 353 -359.
13. McLeroy, K.R. et al. "Creating Capacity: Establishing a Re-
search Agenda for Special Populations." Health Education
Quarterly 22 (1995): 390 -405.
14. Marin, G. et al. "A Research Agenda for Health Education
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APPENDIX
Implications of Seven Major Trends on Public Health Research, Practice, and Education
Implications
Trend
Research
Practice
Education
Aging of the
population
• increasing opportunities for all re-
search addressing health issues in
• need for identifying effective strategies
for marketing health promotion programs
• need for teaching students the epi-
demiology and prevention of aging -
elderly populations, including re-
and activities to the elderly, especially
related disorders
search on the epidemiology of aging-
older males"
• need for teaching resources to meet
related health problems12
• need for accessing new research findings
the educational needs of older stu-
• need to develop new and effective
on disease prevention for the elderly, and
dents returning to college for educa-
interventions for promoting healthy
translating those findings into effective
tion in public health
lifestyles among the elderly to im-
programs
prove quality of life and reduce the
complications due to disabling con-
ditions
• need to determine the effectiveness
of community -based approaches that
focus on improving the health, func-
tional status, and quality of life of
the elderly''
Changing pat-
terns in the
• need to ascertain the most relevant
risk factors and to identify effective
• need for strategies to translate known pre-
vention technologies to the highest risk
• need for recruiting into the field of
health into
U.S. racial/
means of delivering culturally ap-
segments of the population in culturally
public and educational
programs a more ethnically diverse
ethnic com-
position
propriate interventionsl*
• need to determine the effectiveness
appropriate ways
• need for providing effective cultural com-
and multilingual population
• need for increasing minority repre-
and acceptability among ethnic
petency training to practitioners
sentation in faculty and student
populations of programs and inter-
• need for strategies to empower ethnically
body of schools of public health's
ventions that have been effective in
diverse communities and help them take
• need for providing cultural compe-
the general population"
action to improve health and conditions
tency training as part of public
of living
health education's .
• need for promoting among all popula-
tions, especially the dwindling white ma-
jority, a recognition of public health as a
"common good"
Changes in
health care
• new opportunities for collaboration
between schools of public health
• greater opportunity to "market" preven-
tion, especially among managed care pro-
• need in public health curricula for
enhanced courses that describe the
delivery sys-
and managed care providers, espe-
viders and HMOs"
changing health care system focus
tems
cially in the areas of prevention pro-
• need for developing prevention - related
needs to include the system and the
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Implications
Trend Research Practice Education
gramming, program evaluation, out-
comes research, and cost - benefit and
cost effectiveness analyses'
need to increase the adoption of out-
come measures as policy makers as-
sess the performance of the health
care system1°
increased emphasis on evaluation of
prevention programs and services
provided in health care settings as
well as community settings
need for creating programs at federal,
state, and managed care organization
levels to build a support base for
psychosocial behavioral research'
Explosion of in- • opportunities for engaging in col -
formation laborative research with both public
technologies health and health care organizations
on the application of integrated data
systems'
• opportunities for universities to
work closely with health care pro-
viders and others to more effectively
deliver and communicate prevention
messages (e.g., no- smoking advice,
mammography screening)
• new opportunities for secondary
data analysis will be created by es-
tablishing linkages between existing
data sets collected by public health
agencies and managed care providers
surveillance systems, such as report cards
to measure quality -of -care, and private -
public collaborations"
• increased demand in health care settings
for workers with an orientation toward
community health— serving the entire
population'
• increased emphasis on evaluation of pro-
grams and services provided in health
care settings
• need for public health organizations and
practitioners to recognize and embrace
the market - driven changes in provision of
health care, and not ignore them based on
philosophical or ideological objections'
opportunities for universities to work
closely with health care providers to more
effectively deliver and communicate pre-
vention messages (e.g., no- smoking ad-
vice, mammography screening)
opportunities for universities and govern-
ment agencies to establish and maintain
websites on the Internet as up -to -date in-
formation and research resources for prac-
titioners and for the general public
environment that is driving change
• need for public health students to
more fully understand the eco-
nomic implications of changes in
the health care system — economic
value of prevention becomes-In-
creasingly important—need for ap-
propriate use of cost - effectiveness
analysis'9-20
• need for teaching concepts of
health status measurement, out-
comes assessment, epidemiology,
and health promotion and disease
prevention to students in health ad-
ministration programs " -='
• need for teaching clinicians about
community assessment, prevention,
health promotion and disease pre-
vention, and a population perspec-
tive''
• need for programs in schools of
public health to emphasize admin-
istrative and business skills in the
context of public health
• need for teaching public health pro-
fessionals how to locate and use
modern data systems
• need for using distance learning
technologies to more effectively de-
liver public health education
• need for public health students to
learn to navigate the Internet and
other information technologies
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Trend
Research
Changing needs
• need for researchers to establish and
in public
use skills in conducting literature
health work
syntheses and/or meta - analyses
force
• need for a stronger commitment
among public health researchers to
work toward more efficient and
timely translation of research find-
ings into practice recommendations
Growth in • need for conducting research to de-
health- related termine how and which theories and
partnerships principles of community and indi-
vidual health behavior can be ap-
plied most effectively and efficiently
to community practice"
• need for identifying ways to increase
the capacity of nonhealth organiza-
tions to deliver health - related pro -
grams" and to conduct business in a
way that enhances the health of
workers
Anti - govern-
• need for universities to seek more re-
ment senti-
search funding from agencies outside
ment and po-
the federal government, including
larization
managed care companies, philan-
thropic'organizations, and state and
local governments
• opportunities for conducting policy
research, such as assessing the effect
of changing public health policies
(e.g., do the new block grants work ?)
• need for prevention researchers to
build a "research machine" like
bench scientists have been success-
ful in doing
•
Implications
Practice
• need for more entrepreneurial public
health leaders, those with the ability to
recognize and use innovation
• need for public health leaders who can
bridge the gap between private and public
sectors, those with the ability and com-
mitment to build strategic alliances
• need for practitioners to be better trained
in ways to systematically communicate
complex scientific information to the
public
• increasing opportunities for building part-
nerships with public and private commu-
nity- based organizations16
• opportunities to emphasize that partner-
ships between universities, health agen-
cies, and communities must be true col-
laborations in which all parties share
responsibility in the development of the
public health agenda 27
• opportunity for the public health commu-
nity to offset some anti- government senti-
ment and misconceptions through the
well - established process of coalition
building —Le., bringing together diverse
individuals and agencies to pursue com-
mon health - related goals
• need for organizing communities and coa-
litions for activities such as needs assess-
ment and advocacy, to increase communi-
ties' ability to lobby and compete for
funding allocated by state and local agen-
cies
• need for public health professionals to
Education
• need for linking in -class curricu-
lum, internship experience, and
necessary job skills (core competen-
cies)
• need for establishing more intern-
ships that bridge the private and
public sectors
• need for teaching physicians ad= `
ministrative and management
skills, and population -based sci-
ences such as epidemiology
• increasing need for teaching leader-
ship skills for public health and
health care administrators
• need for incorporating the experi-
ences of practitioners in classroom
education
• need for creating new internship
opportunities in community set-
tings and nontraditional settings
• need for preparing public health
students to work effectively within
changing public health and health
care organizational structures
• need to better prepare students to
understand how national, state, and
local laws and regulations affect the
health of the public
• need for public health professionals
to receive better training in media
advocacy and as media liaisons to
enhance their ability to disseminate
messages about public health
through the media
•
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raise awareness and appreciation of pub-
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lic health among the general population
by pointing out public health services
that benefit all, but are taken for granted,
using relevant local examples to illustrate
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the value of public health (e.g., a system
of "profiling the best ")
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Prevention, Public Health, and Managed Care:
Obstacles and Opportunities
Emily Friedman
his conference was convened because managed
care and public health have been pursuing quite
different paths in terms of prevention, and
there is more than a little tension and competition
afoot, as there usually is when jobs, prestige, and money
are on the line. This is complicated by the fact that
neither side is exactly a monolith: in public health,
there are contrasts between understaffed, underfunded
county health departments nationwide and the well-
funded, renowned national infectious disease program
at CDC. The managed care world is similarly character-
ized by lavishly capitalized health plans, led by multi-
millionaire chief executive officers, and thinly funded
non -profit plans struggling to serve Medicaid, disabled,
and other vulnerable patient populations. The lack of a
binding sense of unity around prevention is therefore
not surprising.
Beyond that, there are at least three legitimate dif-
ferences between public health and managed care that
can impede collaboration on prevention. First, al-
bough both have responsibility for populations, man-
aged care gets to choose its populations, whereas public
health is responsible for everyone. For a long time,
managed care's main constituency was young, em-
ployed, reasonably healthy groups of people --not the
most intractable population in terms of health. More
recently, managed care has expanded into Medicaid
and Medicare and is beginning to serve more difficult
populations. In some cases, this change is proving to be
a far superior way of organizing care for these vulner-
able groups. In others, though, it has been a calamity
characterized by brutal risk aversion by some managed
care plans.
The result has been lawsuits, injunctions, and, in
many cases, lackadaisical regulatory response. Although
Congress and state legislatures have been passing man-
aged care legislation at a breakneck pace, too much of
it has consisted of dictating how care is to be provided
on a diagnosis- specific or procedure - specific basis, a
terrible precedent in terms of clinical autonomy and
quality of care.
Contributing Editor, Hospitals and Health Networks and Healthcare
Forum Journal and Section Editor, Journal of the American Medical
Association.
Address correspondence to: Emily Friedmon, Unit G, 851 West
Ommison Street, Chicago, Illinois 60640
102 Am J Prey Med 1998;14(35)
® 1998 American journal of Preventive Medicine
Meanwhile, at least 40 states plan to implement
Medicaid managed care. This will increase the number
of sicker people in managed care plans; a study by the
Kaiser Family Foundation in 1996 found, for example,
that 30% of all [welfare] families have at least one
disabled member. Seeking to enroll these fragile pa-
tients in some managed care plans will not produce a
good match in all cases, particularly if plans continue to
skim on the basis of patient health status.
In contrast, public health does not enjoy the luxury
of selectivity; it has to protect everyone. Moreover, as
the skimming goes on, public health is ending up with
responsibility for more of the sickest and most difficult
patients while the money goes elsewhere.
Public health is also picking up persons technically
enrolled in managed care who continue to seek public
health services, as well as those who are being dropped
from - Medicaid — including the 180,000 persons
dropped last year who had been deemed disabled by
reason of substance abuse, and long -term [welfare]
families and some immigrants who may be dropped
soon. The effect, intentional or not, is that even the
Medicaid population deemed eligible for managed care
is being cleansed of bad risks and difficult populations.
As for the uninsured, their numbers keep rising.
According to the Census Bureau, 40 to 45 million
people lack coverage most or all of the time. The
private sector, though, is not hurrying to sign them up.
Managed care can pick the populations for which it
takes responsibility; public health cannot. This is a
major source of tension between the two.
A second difference is that public health's mission is
well defined, whereas managed care serves many mas-
ters. In managed care, which master you serve has
everything to do with ownership and structure.
I disagree with Dr. McGuire's view that the issue is
not for - profits versus non profits or integrated versus
non - integrated plans. These are precisely the issues.
Most HMOs today are for -profit, and almost all of them
are publicly held and are thus accountable to stock-
holders and to the Wall Street brokers who rate their
stock. This is appropriate for a publicly held organizes
tion, but it raises questions about whether such ac-
countability is appropriate for health care. In contrast,
non - profits are first accountable to their boards, the
0749 - 8797/98/$19.00
PH S0749- 3797(97)00034 -2
99
Internal Revenue Service, the state government, and, in
many cases, their members and communities.
Furthermore, most HMOs are not integrated. An
integrated plan employs or exclusively contracts with
physicians in group practices, likely owns some or most
of the hospitals that serve its members, and provides
most services in a reasonable continuum of care. An
IPA or broker -type plan simply makes a deal between
payers and providers, transfers much or even all the risk
to the providers, and'takes as much as a third of the
premium money as its-payment.
An integrated plan actually provides services as well
as collecting premiums, and it bears the risk. It makes a
difference, in terms of a commitment to prevention,
whether you are required by law to provide community
benefits or are required by law to maximize profit for
stockholders. It makes a difference in terms of access,
in terms of quality of care, and in terms of which master
you serve.
This is not a dilemma faced by public health.
Whether its structure facilitates it or not—and often it
does not, whether the funding is there or not—and
often it is not, public health is supposed to protect the
public —all of the public. Some health plans do serve
the public and serve it brilliantly. Others do not It
makes a difference.
A third area of difference is turf and money. The
positions of the combatants appear to be that managed
care is attacking and winning public health territory,
with public health on the defensive and being beaten
back. The question is what managed care will do with
the territory it wins if it is able to hang on to it. Fears on
the part of the public health community that some
plans will just take the money and run are thoroughly
justified.
Concerns also center on the many faces of preven-
tion. Some consultants and managed care advocates are
now suggesting that all prevention and public health
activities can be taken over by managed care plans.
Well, perhaps in a perfect world; but I cannot see
health plans figuring out which part of the water supply
to protect because they are only responsible for their
own members, or surveying their members about the
restaurants they eat in so that they only have to worry
about salmonella in those restaurants. This may seem
far- fetched, but as competition for patients, turf, and
funds increase, many health care entities will be actively
seeking new worlds to conquer.
On a larger scale, if we decide that the CDC is,
superfluous, who will do the epidemiology in the face
of new disease agents attacking us from all sides?
On the other hand, the managed care community's
frustration with the parochialism, paranoia, and arro-
gance of public health people is also sometimes justi-
fied. If public health is so wonderful at prevention, why
are so many of our 2-year-olds not immunized? Why are
100
we struggling with antibiodc- resistant tuberculosis and
pneumococci? Why did dozens of American children
die of measles in 1991? This is hardly an advertisement
for the achievements of public health. Maybe Aak
could learn something from truly integrated, commi
red health plans.
The most remarkable thing about this conference,
then, is that so many participants were willing to put
aside their differences and start talking to each other. It
has not been without suspicion and tension, of course,
but, for the most part, this has been a good start.
If the overcoming of these differences or at least
the opening of negotiations —has been the most visible
accomplishment of this conference, the most impor-
tant responsibility of the people here is to accept that
managed care and public health share an enormous
amount when it comes to preventive health. Not all of
what they share is positive, but much of it is.
First, you share three obstacles to improving both the
theory and practice of prevention in this country. As
Dr. Smith said, this is not a country or culture that
exactly worships at the altar of prevention. We talk a
good game, but the fact is that we glorify anorexia; we
price health clubs and equipment out of the reach of
the persons who could benefit from them the most; we
preach fresh fish and vegetables to people who are
trying to raise a family on $13,000 a year and whose
supermarkets are in 7- Elevens; and we market a healthy
lifestyle characterized by grueling exercise, nothing fun
to eat, no cigarettes, no alcohol, no drugs, and exho0
tations to watch the stress levels. And then we wonder
why people don't flock to our banner.
At the same time, when people do not live up to our
expectations, we scorn them. As Dr. Roger Evans of the
Mayo Clinic has written: "As we pursue the ideology of
preventive health, those persons who have inherited or
acquired health deficiencies for which they are consid-
ered responsible will necessarily be viewed. as pariahs
who place excessive demands on society."' He argues
that we view these people as failures —and that our
sociopolitical system does not like to reward failure.
Public health has been able to slip prevention (in
small doses) into schools, onto radio and television,
and in some cases into the popular culture. On the
other hand, managed care has included preventive
services in the regular regimen of care, something that
the fee - for - service system and the insurers who paid for
it not only did not do regularly, but excluded from
most policies. So managed care is doing something
right in that regard. The fact remains, though, that all
of us must work harder to make prevention easier,
more accessible, and more attractive in a country that
essentially still refuses to take it seriously.
Another obstacle is that Americans are distrustful of
public functions, whether they are provided in the
public or the private sector. This country was settled by
Am J Prev Med 1998;14(35) 103
anti- government radicals whose philosophy still holds
sway. Moreover, the average American's fear of bureau-
crats is so pervasive that we seem to be expecting less
and less of the public sector. Therefore, even a private
HMO trying to encourage smoking cessation and
weight control must contend with patient distrust and
apprehension about "Big Brother " –like behavior. Man-
aged care and public health both have to do a better
job in dealing with paranoia about our intruding too
deeply into people's private lives, asking too many
questions, and being careless with data and information
that can ruin someone's life.
Also, we must become much more serious about
evaluation, outcomes, and implementation. Prevention
theory needs to become prevention practice, and
guideline theory needs to become protocols that peo-
ple pay attention to. As for evaluation and outcomes, we
see too much anecdotal data being presented as gospel,
shady statistics whose origin is always proprietary so that
their legitimacy cannot be assessed, public opinion
surveys that have been manipulated into meaningless-
ness, and scare tactics that result in a rush to judgment.
Like the'rest of health care, prevention has become an
industry, and it, too, wants to justify its existence. At
these prices, however, maybe we should cast a colder
eye on what we are doing and find out what really
makes a difference.
One clue could come from the great economist Eli
+� Ginzberg, who conducted an exhaustive study of the
impact of the health care system on poor people in the
United States. In his book, Tomorrow's Ho*itaf, he
concluded that the health care system's greatest contri-
bution to the health of the poor is to employ them and
thereby get them out of poverty --the single most
important determinant of a person's health.' Thus,
there are undoubtedly some problems we should throw
money at, but they may not be clinical in nature.
These are obstacles faced by anyone and any
organization, public or private, that really wants to do
prevention.
Fortunately, there are three shared opportunities as
well. First, although it has been obscured by time,
politics, and distractions, managed care and public
health started out with a shared vision. The first health
plans, which were non - profit, community - oriented, and
highly integrated as service providers as well as insurers,
put a high premium on keeping people healthy. The
almost limitless opportunity to spend money on the
front end has always been available to both health plans
and the public health community. In the end, the goals
are the same, even if they were derived from strikingly
different organizations and traditions. The recent
emergence of managed care as an investment opportu-
nity and an avoider of risk has obscured that shared
0 ision, but if we clear away the smoke, it is still there.
Second, the good guys are in it for the long term.
Despite the rumors of its demise, public health isn't
going anywhere. Neither are the oldest integrated
health plans. Both plan to stick around, and that means
being able to reap the rewards of prevention, i.e.,
seeing children grow up having never smoked a cigar
rette, snacked on lead paint, or been struck by a parent
in anger.
Third, both public health and good managed care
can redistribute any savings achieved through success-
ful prevention activities. There are many opportunities
to do enormous good with the money saved by organ
nizing care better and practicing meaningful preven-
tion: extension of coverage to the uninsured, environ-
mental health initiatives, real violence prevention on
the streets and in our homes, facing up to hunger and
homelessness.
Of course, any savings achieved by prevention activ-
ities can be stolen or squandered, and there is still
debate as to whether prevention does, in fact, save
money — although I, at least, believe it does. But on the
assumption that at least some savings will be achieved,
there is a world of opportunity for those organizations,
public and private, that can capture the savings and
reinvest them in their communities. What a chancel
This is what you share. This is what we all share. This
is a rich enough possibility that it is worth giving each
other the benefit of the doubt.
I will close with three suggestions to you as organiza-
tions and three to you as individuals.
As organizations; first, pick your fights about content
and turf. We need to focus more on what matters. My
discussions with health plan representatives about what
we really know about prevention have yielded three
thoughts: (1) tobacco is really bad for you; (2) some
exercise —which can be no more complicated than
taking a walk —is really good for you; and (3) depres-
sion, even mild depression, makes almost all other
threats to good health worse.
Similarly, in terms of turf, protect what must be
protected, and give' way when you should. Public
health's turf clearly includes restaurant inspections,
food and water safety, epidemiology, and other things
that public health has always done and that must be
done for everyone. Managed care's turf centers on
more circumscribed populations and goals. Give way
when you should. No one will win them all, but know
which ones you can win —and what is worth fighting for
in the first place. 1.
Second, find out who does what best, and support
them. That could mean having health plans fund
public agencies, public agencies fund health plans, or
both fund a third party, e.g., an AIDS hospice, a feeding
program, or a summer camp for lour- income children.
Do not reinvent the wheel. Do not duplicate existing
excellence. Do not compete for the sake of comped-
104 American Journal of Preventive Medicine, Volume 14, Number 3S
101
I
1
i
i
I
tion. Follow the maxim enunciated by Henry Kaiser.
find a need, and fill it.
Third, do not provide prevention and screening
without follow-up. What good is colorectal screening if
surgery is not available when tumors are found? What
good is violence counseling when a battered woman
has nowhere to go except back to her torturer's home?
For that matter, why do we continue to immunize kids
against disease and then send them home into violence,
poverty, and despair? Prevention is only a means, a first
step. Too often, though, it .becomes an end in itself.
Finally, there are three challenges to you as individ-
uals. First, why are you in prevention? I hope it is not for
recognition, job security, or protection of your tax-
exempt status. Working in prevention is a high calling,
the most honorable kind of work. We should all take
pride in being involved in it because it protects the
length, quality, and dignity of human life —and because
it is what a civilized society should do. That has nothing
to do with money or turf.
Second, what are you willing to give up in the pursuit
of prevention? Will you concede some turf? Will you
relinquish some power? Will you share your money and
resources? Most important, are you willing to risk
failure?
Joycelyn Elders, MD, our last visible surgeon general,
knew that bringing up the possibility of legalizing illicit
drugs and discussing masturbation as a means of pre-
venting sexually transmitted diseases was not likely to
win her support. She was willing to take the risk in the
service of public health, and she got fired. However, she
wrote a beautiful piece after her forced resignation in
which she said two things: (1) It is time to tone down
the rhetoric in our discussions of health policy, and (2)
if her actions had saved one child from being infected
with HIV, she would find the whole experience worth-
while.
In prevention, we are constantly asking others to give
things up. We should also ask ourselves what we are
willing to give up and what risks we are willing to take
on behalf of what we believe.
Last, we are, after all, in Atlanta, and yesterday was
the birthday of this city's magnificent son, Martin
Luther King, Jr. He, too, was willing to lay it on the line
because of a simple belief. He believed, profoundly, in
the value of every human being and the dignity of every
person. In that sense, he, too, toiled in the vineyards of
102
public health. He knew that there are some things we
can only accomplish together. He knew that, whether it
is the rights of men and women to be respected as me
or women or the rights of people to have a chance
good health, individual effort can go only so far.
It is an understanding echoed by the philosopher
Alistair Campbell, who wrote, "The aim of all health
care is a shared freedom, whereby one finds one's
aspirations fulfilled, not only by having one's own
needs met, but also by participating in a society in
which those who are at the greatest disadvantage can
equally find the means to personal fulfillment. "s That
may not be the heart of prevention, but it is close.
In Tom Stoppard's play Rosencrantz and Guildenstern
Are Dead, the two main characters have been killed, are
being carried off at the end of the play, and are having
a chat. (It's a surrealistic play.) Rosencrantz says to
Guildenstem, "You know, somewhere along the line
there must have been a point where we could have
stopped and said 'No.'" And Guildenstern replies,
"Yeah," but I guess we missed it."
In this country, we are at a crossroads between
Alistair Campbell's vision of health care as a shared
value — something we all own and to which we all must
have access —and the nightmare of a health care Third
World in which a fat, bloated health care system
lavishes its services on the insured rich while uninsured
children and the excluded poor die of measles an
�
polio. It seems to me that the choice is easy enoug
especially in terms of what we want our legacy to be.
So I hope that, when those who come after us look
back at us from the future, they will know that, in
preventing what could be prevented and in protecting
those whose sorrows could not be avoided, when the
point came when we were asked if we had the courage
to do what needed to be done, we stood up and said,
"Yes."
References
1. Evans, R Rationale for rationing. Health Manage Q 1992;
14(2):14 -17.
2. Ginzberg, E. Tomorrow's hospital: a look to the 21 st
century. New Haven: Yale University Press, 1996.
3. Campbell, A. Health as libertion. Cleveland, OH: Pilgram
Press, 1995.
0
Am J Prev Med 1998;14(3S) 105
I �
1 ACCESS TO
HEALTH CARE IN
�
NORTH CAROLINA
� Indicators and Baseline Data
1996
z
G.
e
Author — Kathryn Surles
Quality Control — Amy Cox
Graphics — Carol Schriber and Frank Mathews
Layout and Typesetting — Jean Stafford
N.C. Department of Environment, Health, and Natural Resources
State Center for Health Statistics
Raleigh, North Carolina
M
ALLLLLLLLLLL
No* Carolina nibbe Haallh
103
t is often said that children are society's
most valuable resource. Thus, it is very dis-
turbing that the national KIDS COUNT
1995 ranking of states placed North Carolina
42nd. That means, based on a composite score
for 10 key indicators of the well-being of young
children and adolescents, ours was the 9th worst
state in the nation.'s
Childhood provides a critical window during
which to establish good health practices, detect
impairments, and intervene early. The American
Academy of Pediatrics (AAP) recommends a
schedule of six well-child visits during infancy to
CHILD HEALTH
provide adequate immunization against childhood
diseases, conduct routine assessments, and pro-
vide counseling to parents. The AAP also recom-
mends three well-child visits during the second
year, then annual visits through age 6, and one visit
every other year thereafter. Additional visits may
be needed for acute episodes or chronic condi-
tions.'
Eight access indicators for child health fol-
low. A desired but unavailable indicator is the
percentage of pediatricians and general/family
practitioners participating in Medicaid.
Access to Health Care in North Carolina
Fzs
104
•
•
•
•
•
•
26
CHILD HEALTH
► Indicator 9: Percent of Children Unin-
sured
As Medicaid programs have expanded
nationwide, the percentage of children with no
health insurance has declined slightly. Still, in
North Carolina and the United States in 1990-
92, more than one child in 10 had no health
insurance.
Data from the 1995 North Carolina Health
Profile telephone survey show that only 7.2
percent of children under age 18 were without
health insurance during the past year — 4.7 per-
cent of white children and 13.5 percent of mi-
nority children. Since households without
m
m
m
c
c
m
to
c
m
a
telephones were not included, the true percent -.
ages are probably higher.
Lack of health insurance may be the most im=
portant barrier to health care. Although insur-
ance does not assure access to care, it has been
documented that children who have health cov-
erage through private means or through Med-
icaid see a physician more frequently than
children without the coverage."
In addition to uninsurance, underinsurance may
result in limited access to health care —
because preventive or acute can is not covered or
it is covered only with significant copayments s
Percent Difference in Health Insurance
Coverage of Children Under 18
North Carolina, 1990 -92 compared to 1988 -90
50 -
42.2
40
30
20
10
0
-10- -7.9
-20 Employer' .Medicaid
-7.9
Other Uninsured'
Insurance
Insurer
•Includes ehlaron covered as depe AWft an the empb)w group Insurance of another fw* number.
Note. Data are from the uS. Current Populadon sunny, as eompled by The urban Institute7 see
e3Plsnabon of the estimates on paps S.
Access to Health Care in North Carolina
105
CHILD HFALTH
9. More than 1 child in 10 has no health insurance
c
'c
m
ciy
0
3
m
W
c
7
c
U
O
c
a�
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tb
n.
25-
20 -
15-
10-
5-
0-
12.7
J J 1
North Carolina
15.1 14.7
South Atlantic
Area
12.4
Jr I
United States
Note: Data are from the U.S. Current Population Survey, as compiled by The Urban Institute7See w0anatkn
of the estimates an page 5.
`2 %
Access to Health Care in North Carolina
106
•
•
•
•
•
10
28
CHILD HEALTH
► Indicator 10: Percent of Eligible Chil-
dren Enrolled in Medicaid
The state's Medicaid program grew substan-
tially after new income eligibility levels were
established in October 1990 and during in-
creased unemployment in 1991 and 1992.11 As
a result, the percentage of all children (under
age 18) enrolled in Medicaid rose 42 percent
between 1988 -90 and 1990 -92 to 21, the same
percentage as the nation's.
Unfortunately, the state's Medicaid program
still enrolled in 1990 -92 a significantly lower
percentage of eligible children (68.7) than did
programs nationwide (75.4)?
Effective July 1, 1994, Medicaid was ex-
panded to cover children aged 10 -18 whose
family incomes are under 100 percent of pov-
erty. The state's Health Planning Commission
has recommended that Medicaid benefits be
further expanded to cover a) infants (under I
year) whose family incomes are below 200 per-
cent of poverty, b) children aged 1 -5 with fam-
ily incomes below 185 percent of poverty, and
c) children aged 6 -18 with family incomes be-
low 133 percent of poverty. The Health Plan-
ning Commission also recommends eventual
Access to Health Care in North Carolina
coverage of all children whose family incomes
are below 200 percent of poverty as well as, for
two years, postpartum women whose family
incomes are below 200 percent of poverty. 10
Data from the 1995 North Carolina Health
Profile telephone survey show that more than
one out of three minority children and 14 per-
cent of white children were covered by Medic-
aid. Overall, 21 percent were in the program,
according to the children's caregivers. Once
again, households without telephones were not
included in the survey.
Even when poor children are enrolled in
Medicaid, access to private physicians may -be
limited due to physicians' unwillingness to par-
ticipate in the program. A recent North Caro-
lina study found that, in 89 reporting counties,
38 percent of general and family practitioners
did not accept Medicaid children under age 5
in 1994. In 74 reporting counties, 27 percent of
pediatricians did not accept Medicaid children
under age 5.19
Data on physician participation in Medicaid are
not routinely collected. The feasibility of obtain-
ing this information should be investigated.
107
108
CHILD HEALTH
10. Medicaid fails to cover 1 out of 3 eligible
children in North Carolina
T
m
:a
-v 6
c �
a�
� U
U �
m�
c
0 0
c �
a� CD
v
a�
a
100-
so-
80-
70-
807
50-
40-
30-
20-
107
0-
.:
North
Carolina
*
75.4
South Atlantic
Area
United
States
Note: Data are from the U.S. Current Population Sunray, as compiled by The Urban Insdtute7See explanation
of the estimates an page 5.
29
Access to Health Care in North Carolina
•
•
•
•
109
CHILD HEALTH
► Indicator 12: Percent of Children Having
a Usual Source of Routine Health Care
The receipt of health care from a regular
source is a concern because it is an indicator of
continuity of care, which can affect the quality
of care as well as the cost.
Most children have a usual source of routine
health care, especially white children and
younger children, as shown by Indicator 12.
The sources of care vary by race, age of child,
and type of care, as shown below. White chil-
dren appear more likely than minorities to go
to a doctor's office or private clinic. When sick
or injured, minority children are more likely
than whites to seek care from hospitals, where
the cost of visits is much higher than the cost
of visits to a doctor's offices
Data for Indicator 12 and below are from the
North Carolina Health Profile telephone survey.
See Technical Notes, page 5, keeping in mind
that these results are based on information pro-
vided by the children's adult caregivers. Data
for children under one are not included because
the survey included too few minorities in this
age group:
Percent of Children by Reported Place of Last Health Care
72.4
in Past Year by Type of Care
82.6
55.3
North Carolina 1995
10.9
16.0 ,
Care When
0.0
Neighborhood or Government Clinic
Sick or Injured
Routine Care
Ages 1 -4 Whites Minorities
Whites
Minorities
Doctor's Office or Private Clinic 75.8 70.0
76.3
61.6
Hospital Emergency Room 10.0 12.4
0.0
1.0
Neighborhood or Government Clinic 6.1 12.6
16.8
19.3
Other* 8.1 5.0
6.6
18.1
Unknown 0.0. 0.0
0.3
0.0
Ages 5 -17
Doctor's Office or Private Clinic
72.4
53.6
82.6
55.3
Hospital Emergency Room
10.9
16.0 ,
0.4
0.0
Neighborhood or Government Clinic
2.9
7.6
8.0
33.1
Other*
13.8
19.7
8,8
11.6
Unknown
0.0.
31
- 0.2
0.0
*Mainly hospital, hospital outpatient clinic, and nonhospital emergency or urgent care center.
Source: North Carolina Health Profile, Fall 1995.
32 Access to Health Care In North Carolina
12.
CHILD HEALTH
Most N.C. children reportedly have a usual
source of routine healthcare
loo-
,
97.2
LO
•r<
OWhites
• a x
w:
k� 4n1
1 ;
•
CL 50-
o `Rq,
1 0 h <$x
• 0 ¢
Mme'
• 20-1
b < \r
Ages 1-4
6o.:rce: North Carolina Health Profile, Fall 1995.
Ages 5 -17
33
Access to Health Care in North Carolina
110
r�
•
•
CHILD HEALTH
► Indicator 15: Preventable Hospitaliza-
tions per 1, 000 Children Under Age 6
Indicator 15 depicts, for total and Medicaid
children under the age of 6, rates of hospital-
ization for conditions that might have been pre-
vented or ameliorated by adequate and timely
primary care. Higher rates for Medicaid chil-
dren may suggest that there are barriers to am-
bulatory care for those children.
Based on results for 1990 -92, the Medicaid
child is at excess risk of hospitalization for se-
vere ear /nose /throat (ENT) infections, asthma,
and gastroenteritis. Trends in these rates bear
watching as efforts are made to improve the pri-
mary care picture for children on Medicaid.
Carolina Access is a new program to provide
a more efficient and effective health care sys-
tem for Medicaid recipients by linking them to
primary care providers who deliver and
coordinate their health care. Begun as a dem-
onstration project in April 1991, the program
had expanded to 38 counties with 221,023 en-
rollees as of December 1, 1995. This repre-
sented about 27 percent of Medicaid enrollees
statewide.
Almost all states and the District of Colum-
bia how have managed care plans for Medic-
aid recipients, involving about one - quarter of
the Medicaid population nationally. Somewhat
surprisingly, given many providers' past reluc-
tance to accept Medicaid reimbursement rates,
competition to run the new Medicaid managed
care contracts is strong.'
Future updates of this report should examine
Indicator 15 for Carolina Access counties ver-
sus others. After several years of experience
with the program, Medicaid enrollees in partici-
pating counties should be at lower risk for po-
tentially preventable hospitalizations.
Rates of Preventable Hospitalizations*
Total and Medicaid Populations Under Age 6 in North Carolina
,,,, Total discharges
M Medicaid discharges
III
Potend* avoidable with adequate and timely primary cam.
See cwt nd", opposlb.
Access to Health Care in North Carolina
I
25
I
112
CHILD HEALTH
Chart Notes:
• Conditions are "ambulatory care sensitive" conditions identified by the Ambulatory Can Access Project, United
Hospital Fund of New Yorks See list of disease codes, page 81.
• Numerators of the rates are calendar year counts of principal diagnoses (with some exclusions). For Medicaid,
numerators are uses identified as Medicaid pay plus "indigent care" and "charity" uses. Many of those cases are
found post - discharge to be eligible for Medicaid pay. Counts are by year of discharge using files of the N.C. Medical
Database Commission.
• Denominators of the total rates are population counts provided by the Office of State Planning. Denominators for
the Medicaid rates are federal fiscal year unduplicated counts of Medicaid - eligibles, provided by the Division of
Medical Assistance.
39
p Access to Health Care in North Carolina
II -
r
J�
L
1
e�
e
dults need routine primary care just as
children do. Unfortunately, personal
income and health insurance coverage
too often determine: the frequency of such care.
Among the Year 2000 health objectives for
the nation are a number of risk reduction and
service objectives that target adults. Those in-
clude objectives to increase the proportion of
adults who have recently had a variety of car-
diovascular and cancer screening tests and the
ADULT HEALTH
proportion of older adults who have had flu and
pneumonia immunizations. Other objectives
stress education and counseling, which are
clearly critical to maintaining health and pre-
venting disease in the adult population.2
Twelve access indicators for adult health fol-
low. A desired but unavailable indicator is the
percentage of internal medicine and general/
family practitioners participating in Medicaid.
Access to Health Care in North Carolina
113
42
ADULT HEALTH
► Indicator 17: Percent of Working -Age
Adults Uninsured
Uninsured adults ages 18 -64 are less likely
than those who are insured to receive inpatient
care and nonemergency ambulatory care.
Among those with chronic or serious medical
problems, the uninsured are more likely than
their insured counterparts to need — but not to
receive — ancillary services (such as physical
therapy, nursing care), medications, and equip -
ment.6
In contrast to the situation for children
(Indicator 9), the percentage of working -age
adults who were uninsured rose between 1988-
90 and 1990 -92, by 13 percent in North
Carolina. These results may reflect increased
unemployment during 1991 and 199218 or other
factors related to a national decline in the per-
centage of working -age adults covered by em-
ployer- sponsored insurance?
Younger adults (ages 18 -34) are particularly
likely to have no health insurance. The state's
percentage (21.1) is below the nation's (22.6);
however, this may reflect that North Carolina
has an above - average concentration of manu-
facturing employers who are more likely to pro-
vide insurance.
For working -age adults, data from the 1995
North Carolina Health Profile telephone survey
show that 17 percent of minorities compared to
11 percent of whites had no health insurance
during the past year. Since households without
telephones were not included in that survey, the
true percentages are probably higher.
As was noted earlier for children, under -
insurance may also result in limited access to
health care — because preventive or acute care
is not covered or it is covered only with signifi-
cant copayments 5
Percent Difference In Health Insurance
Coverage of Adults Ages 18 -64
North Carolina, 1990 -92 compared to 1988 -90
50
m
40-
30 _ 25
5 20
12.8
10-
= .0.9
0=
a -4.4
-10 Employer' Medicaid Other Uninsured
Insurance
Insurer
Includes persorm covered an dependents on the employer group
Insurance of another family member.
Note; Data we tmm the U.S. cu"wo Populadm Survey, as compiled by The Urban ImtkIIIJ
See explwlicn d the eatlrtulea cn pope L
Access to Health Care in North Carolina
114
lei
"I
0
0
IL
i
n
i
:J
4
f
t
I]
4
4 -
LI
ADULT HEALTH
17a. The percent of working -age adults who are
uninsured Is rising
25- .
20- 20
16.8 17.3 17.7
•<.. 16.2
14.9
:4 :v4• _
A:S v.. { Yip.:: '^•�r+y4••' ?' '3 4}.i' `.
w > ?:; f•,';{: � rye:.}, �'r'% }ti F'.,ry;.{'�: ?4 ••Y.
m:
�. - k.•ri4,�y::i�v:4: H..• v:'.:v?'v?? :i: {•.. S:i. hv'•?h4•::% .
{9riJ :�+ ++v.:ii}:ti{•:•:Sv4:�: j �.: •., ::yry,
ff4. . = '6J:{•.}JY;: �:j•:•:
CL
22yy }i S• :
A - .�•.�•`+n',�.••hv<,�} xk'�• 4w:{:v]i }i: :}}i:vi•'!m'GKWh{
United States
South Atlantic
Area
17b. Young adults are the most likely to be
uninsured
N 30 -
25 -
2 20-
3 -
252
North Carolina
-South Atlantic area
I Unted States
Access to Health Care in North Carolina
115
i '"
15.8
15-
13.9 4y 14
�..
13.2
.mac 10 -
{'
CL
0-
Age 18-34
Age 35-53
Age 5464
Note Data an from tM U.S. current Population Survey, as compied by
The Urban IneMM 7
See eplanatian d dw estimates an page 5.
Access to Health Care in North Carolina
115
i '"
ADULT HEALTH
► Indicator 18: Percent of Eligible Work-
ing -Age Adults Enrolled in Medicaid
About 11 percent of the state's working -age
adults were eligible for Medicaid in 1990 -92.
Of those, only 62.5 percent were enrolled. That
percentage is significantly lower than the U.S.
average (71.5).'
The state's Health Planning Commission has
recommended that Medicaid benefits be ex-
panded to cover more adults: a) pregnant
women whose family incomes are below 200
percent of poverty, b) for two years, postpartum
women whose family incomes are below 200
percent of poverty, and c) the elderly and dis-
abled whose family incomes are below 100 per-
cent of poverty. The Commission also recom-
mends eventual expansion of Medicaid to cover
the elderly and disabled whose family incomes
are below 200 percent of poverty.10
Access to Health Care in North Carolina
Based on self reports by working -age adults,
data from the 1995 North Carolina Health Pro-
file telephone survey show that 3 percent of
whites and 16 percent of minorities were cov-
ered by Medicaid during the past year. Among
adults 65 and older, 10 percent of whites and
34 percent of minorities said they were covered
during the past year. Again, that survey ex-
cluded households without telephones, so the
percentages *are probably underestimates.
Failure of physicians to participate in Med-
icaid also limits the working -age adult's access
to health care. As was noted for children (Indi-
cator 10), the feasibility of obtaining this infor-
mation should be investigated.
v
0
;2
r
n
h
M
M
117
ADULT HEALTH
18. Medicaid fails to cover 4 out of 10 eligible working -age
adults /n North Carolina
N
0
100-
v
so-
80-
70-
v -
�' 60 -
e
c -
d
50-
-
°r°
40-
30-
20-
79 -
e 10-
c
V
0-
CL
62.5
North
Carolina
.M.:
South Atlantic
Area
71.5
United
States
Not Data are tram the U.S. Current Populsdon Surrey, as compiled by The Uran b Insdtute.T
e:
See a)lamation of the estimates cn page S.
45
Access to Health Care in North Carolina
ADULT HEALTH
► Indicator 19: Percent of Adul& Having a
Usual Source of Routine Health Care
As was noted for children, the receipt of
health care from a regular source is a concern
because it is an indicator of continuity of care,
which can affect the quality of care as well as
the cost.
Most adults have a usual source of routine
health care, especially white adults and older
adults, as shown by Indicator 19. The sources
of care vary by race, age, and type of care, as
shown below. Whites appear more likely than
minorities to go to a doctor's office or private
clinic. Minorities are more likely than whites to
seek care from hospitals, where the cost of vis-
its is much higher than the cost of visits to a
doctor's office.'
Data for Indicator 19 and below are from the
North Carolina Health Profile telephone survey.
See Technical Notes, page 5, keeping in mind
that these results are based on self - reports.
Percent of Adults by Reported Place of Last Health Care
63.4
in Past Year by Type of Care
89.6
68.8
North Carolina 1995
7.5
14.3
Care When
3.4
Neighborhood or Government Clinic
Sick or Injured
Routine
Care
Ages 18.64 Whites Minorities
Whites
Minorities
Doctor's Office or Private Clinic 65.9 52.3
79.8
58.6
Hospital Emergency Room 8.8 9.4
0.1
1.0
Neighborhood or Government Clinic 4.6 5.8
5.3
18.8
Other* 20.5 32.0
14.7
20.4
Unknown 0.2 0.5
0.1
1.2
Ages 65+
Doctor's Office or Private Clinic
63.4
48.9
89.6
68.8
Hospital Emergency Room
7.5
14.3
0.1
3.4
Neighborhood or Government Clinic
0.3
7.1
2.4
4.4
Other*
27.6
29.7
6.7
22.7
Unknown
1.2
0.0
1.2
0.7
*Mainly hospital, hospital outpatient clinic, and nonhospital emergency or urgent care center.
Source: North Carolina Health Profile, Fall 1995.
46 1
Access to Health Care in North Carolina
118
�9
1
�1
I
0
r
i
r
r
r
i
r
r
ADULT HEALTH
19. Working -age whites are more likely than working -age
minorities to report a usual source of routine health
care
0
LO
T
t
.G
mt
CL c
a°� 5
ao
° o
C
c�
L
m
a
100-
90 -
80-
70
60
50-
40 -
30 -
20 -
10-
0 Ages 18-64 Ages 65
and over
Sourer. North Cardku Heakh Profile. Fd 1995.
•whites
Minorities
47
Acce55 to Health Care in North Carolina
119
ADULT HEALTH
► Indicator 20: Preventable Hospitaliza-
tions per 1,000 Adults 21 -64 Years Old
Indicator 20 depicts, for total and Medicaid
working -age adults, rates of hospitalization for
conditions that might have been prevented or
ameliorated by adequate and timely primary
care. Higher rates for Medicaid enrollees may
suggest that there are barriers to ambulatory
care for those individuals.
Based on results for 1990 -92, Medicaid en-
rollees are at far greater risk than total adults for
potentially preventable hospitalizations. One
confounding factor may be, however, that a
majority of Medicaid adults are women.
Counts of Medicaid enrollees by sex were not
available to compute the sex - specific rates in
order to investigate that potential bias.
Carolina Access is a new program to provide a
more efficient and effective health cart system for
Medicaid recipients by linking them to primary
care providers who deliver and coordinate their
health care. Begun as a demonstration project in
April 1991, the program had expanded to 38 coun-
ties with 221,023 enrollees as of December 1,
1995. This represented about 27 percent of Med-
icaid enrollees statewide.
Almost all states and D.C. now have man-
aged care plans for Medicaid recipients, involv-
ing about one - quarter of the Medicaid popula-
tion nationally.
Future updates of this report should examine
Indicator 20 for Carolina Access counties ver-
sus others. After several years of experience
with the program, Medicaid enrollees in partici-
pating counties should not be at excess risk for
potentially preventable hospitalizations. Indica-
tor 20 also needs to be examined for men ver-
sus women to assess the extent of any sex bias
in the results.
120 1
i
r
r
r
r
r
1
Rates of Preventable Hospitalizations* 11
discharges
�•V WMedicald
discharges
Access to Health Care in North Carolina
il
177
r
•
r
r
ADULT HEALTH
20. North Carolina's poor adults have higher rates
of preventable hospitalizations*
Bacterial . 1 1 1
pneumonia U0.4
kim I I Total
Cellulitis °•6 12 1 I discharges
I 1 I 1
Kidne /urina it Medicaid
Y rY . i 0.9 discharges
infections 2.6 s , 9 ,
Dehydration 0.4 ' '
10.9
Gastroenteritis 1
1 1
Asthma ' .... 1.1
3.7
COPD (Chronic Obstructive iy' 0,7 ,
Pulmonary Disease) IIiW®12
Congestive 1.3 1 I
heart failure LL . 3.7
� 'gyp 9
Angina . V 1.5 '
Diabetes 1.3
3.5
, ,
0 1 2 3 4 5
Discharges per 1,000 people ages 21-64,1990-92
• Potend* avoidable with adequate and timely care.
Chart Notes:
• Conditions are "ambulatory care sensitive" conditions identified by the Ambulatory Care Access Project, United
Hospital Fund of New York.' See list of disease codes, page 81.
• Numerators of the rates are calendar year counts of principal diagnoses (with some exclusions). For Medicaid,
numerators are cases identified as Medicaid pay plus "indigent care" and "charity" cases. Many of those cases are
found post - discharge to be eligible for Medicaid pay. Counts are by year of discharge using 1990 -1993 files of the
N.C. Medical Database Commission.
• Denominators of the total rates are population counts provided by the Office of State Planning. Denominators for
the Medicaid rates are federal fiscal year unduplicated counts of Medicaid - eligibles, provided by the Division of
Medical Assistance.
Access to Health Care in North Carolina 49
121
•
•
;7
I
t
i
t
t
5�
c
t
i�
i
I
i
I
Orange
DEMOGRAPHICS
Number of children, age 0-4
4,386
4,007
5,350
; 5,739
Percent of population, age 0-4
7.6%
5.2%
5.7%
5.2%
Number of children, age 5-17
7,444
11,866
12,388
; 15,319
Percent of population, age 5-17
12.9%
15.4%
13.2%
13.9%
Total number of children and youth, age 0-17
11,830
15,873
17,738
; 21,058
Total percent of population, age 0-17
20.5%
20.6%
18.9%
19.1%
Total county population
57,707
77,055
93,851
; 110,093
Population density per square mile
144.0
192.5
249.0
77
PHYSICAL WELL -BEING
Number of pediatricians
47
62
96 ;
94
Fetal deaths (stillbirths) per 1,000 live births
19.4
12.1
9.9
3.5
Infant mortality rate (per 1,000)
16.6
17.7
10.8
9.8
Percent of low birth - weight babies
8.4%
7.4%
5.4%
6.7%
S'I'D rate among teens (per 1,000)
15.8 ;
13.9
INTELLECTUAL WELL-BEING
Children in subsidized child rue
366
1,469
Children on subsidized child cue waiting list
432
77
Academically gifted students
393
1,048
787
846
Specific learning disabled students
170
492
603
881
Public school retention rate (percent)
69.7%
75.9%
69.9%
Public school dropout rate (percent)
2.8%
1.8%
Per -pupil expenditure in public schools
$948
$1,695
$4,381
$5,637
Middle school students writing at or above grade level
74.4%
69.2% ;
64.2%
Average SAT scores (out of 1600)
914
937
1091
Number of teens not working and not in school
383
262
324
SOCIAL WELL -BEING
Divorce rate (per 100 marriages)
23.3
57.8
46.9
44.8
Percent of children in single parent households
17.3%
24.1%
24.2%
Child abuse and neglect rate (per 1,000)
10.3
11.0
51.1
Rate of children in DSS custody (per 1,000)
3.7
4.2
5.3
Children in foster care placement
13
39
61
Teen pregnancy rate (per 1,000)
49.3
57.1
62.6
39.8
Teen birth race (per 1,000)
69.8
21.3
16.2
14.3
Juvenile custody rate (per 1,000)
2.5
3.2
Number of suicides among youth
0
1
1
1
ECONOMIC WELL -BEING
Median family income
$8,700
$19,305
$40,685 ;
$52,300
Number of children in.poverty
2,248
1,810
1,792
2,286
Percent of children in poverty
19.0%
11.4%
10.1%
10.9%
Percent of single parents in work force
71.4%
63.2%
69.3%
Percent of single parent families in poverty
24.7%
21.7%
20.3%
Number ofTANF recipients, age 0-17
882
774
Number of Food Stamp recipients, age 0-17
1,447
1,676
Children in subsidized school meal programs
2,137
2,175
2,866
1998 NC Data Guide / The Knowledge Excbange / Norm CAROLINA CxnA ADvoc.AcY INSr1TUTE
r
79
122
0
•
•
ORANGE COUNTY HEALTH DEPARTMENT AS A SAFETY NET
PROVIDER
CORE FUNCTIONS OF PUBLIC HEALTH
Assessment of community health status and available resources.
Policy Development resulting in proposals to support and encourage better health
Assurance that needed services are available.
POPULATION -BASED SERVICES
Population -based services are services and interventions which protect entire populations from
illness, disease and injury. They are essential to any effort to address such problems as spiraling
healthcare costs, lack of access to care, and the poor health status of too many U.S. residents.
ESSENTIAL SERVICES ADOPTED BY THE BOARD OF HEALTH
Monitor health status to identify community problems, needs and assets
Diagnose and investigate health problems and health hazards in the community
Link people to needed personal health services and assure the provision of health care, health
education, and outreach services, especially to vulnerable populations
Inform and educate people about health issues
Mobilize community partnerships and action to address community health needs
Develop policies and plans that advocate for and support individual and community health efforts
Assure an expert public health workforce
Evaluate effectiveness, accessibility, and quality of health services
Research for new insights and innovative solutions to health problems
PERSONAL HEALTH CARE SAFETY NET ISSUES
Health departments are the traditional providers for poor and vulnerable populations,
including Medicaid patients and the uninsured/underinsured.
Increasing availability of managed care plans.
Managed care companies and private providers are more willing to take Medicaid patients.
Financial and other access barriers ( geographic, cultural, co- insuranceldeductibles/up -front
payment, etc.) continue to persist for the insured and the uninsured
QUESTIONS
Should the Health Department continue to provide personal health (clinic) services for vulnerable
populations, that is, be the provider of last resort?
If not, who is responsible for providing services to this population?
How do we assure that services are available for this population?
How do we overcome access barriers?