Sign in or 
Share this
Public Health’s Critical Role in Health Reform
Policy statement by primary authors:
Tammy Pilisuk, MPH
CHPPD Section
Member, Federal Activism Council
National Multiple Sclerosis Society
Ellen R. Shaffer PhD MPH
Medical Care Section
Center for Policy Analysis
San Francisco Presidio
P.O. Box 29586
San Francisco, CA 94129
This policy statement is supported by the Medical Care Section and the Community Health and Policy Development (CHPPD) Section of the American Public Health Association (APHA).
It aims to respond to the following topics identified as policy gaps by the Action Board and Joint Policy Council (JPC):
I. Problem Statement
Rationale for Health System Reform
“I take care of an uninsured patient population. Not only am I seeing increased numbers of patients, due to the economic crisis, but patients that have previously had stable medical problems are becoming increasingly less stable related to stress from lack of work and less ability to eat healthfully because of cost. I anticipate an increased incidence of domestic violence, andwomen feeling more "trapped"- and an associated decrease in the availability of programs for assistance... this is all part of things ‘mushrooming.’ “ - Amy Fendrich, M.D. Member, APHA Medical Care Section. Personal communication, February 17, 2009.
The U.S. remains alone among developed nations in failing to provide coverage for health care to all residents. The crisis threatens to become more painful as the economy slows. APHA members are joining with national leaders who are proposing to reform the health system.
An estimated 47 million Americans have no health care coverage (National Physicians Alliance, 2008). There is growing evidence that many of those who have some type of public or private coverage face serious barriers to care, restrictions to allowable benefits, or prohibitive costs (Families USA 2008, Brown et al. 2008). Health care expenditures are increasing at a faster rate than the economy. The New America Foundation has estimated that the US economy lost $207 billion in 2007 because of poor health and shorter lifespan of the uninsured—an amount stated to be the sum total expense of the public cost of providing health care coverage to all Americans (Axeen & Carpenter 2008). In short, the health system is broken because it is not available to everyone. While costs continue to increase, there is no concomitant increase in access to health services or improvement in health outcomes.
Private health insurance plans cover about half the people in the U.S. who are insured, and private funds account for less than half of health expenditures. Most privately insured people obtain insurance based on their employment, and contribute to the cost of coverage. There is no requirement that employers offer health benefits. Private insurance plans vary widely, and increasingly fail to cover basic needs: they may not be affordable, may not cover dependents, may exclude people with certain health conditions or coverage for certain benefits. Employees with job-based insurance can lose coverage if they change jobs, or if employers change the terms of coverage or discontinue it.
In 2008 candidates for president campaigned on proposals for national health reform. Since assuming office, President Obama continues to call for health reform, and leaders in Congress are drafting legislative proposals.
Other groups are looking to join the policy discussion to make sure the needs of their constituencies are considered. Among these, the National Multiple Sclerosis Society's 2008 principles of health care reform (NMSS 2008) addresses seven principles with a focus on individuals with chronic care needs and disabilities. A team from the Mailman School of Public Health developed a set of principles relating to women’s reproductive health (Chavkin et al. 2008)
In 2006, the Citizens' Health Care Working Group convened a series of community meetings that recommended “affordable health care for all Americans” with equitable financing defined as 1) not creating a disproportionate increase in the financial burden on the sick; 2) based on a household’s ability to pay; and 3) sharing the cost among all segments of society. They concluded that government, families, and businesses must be involved in improving health care and that “… [we]need to address the entire health care system,” as well as specific problems in cost, quality, or access…”
The Center for Policy Analysis’ Criteria to Evaluate Health Care Reform (2008) encompasses a broad view of health reform, incorporating the concerns of national public health and women’s groups and emphasizing public health and social justice. It calls for universal, affordable coverage, with fair and stable financing, that controls costs; an accountable delivery system that offers quality, appropriate, accessible and equitable care; eliminating social and economic disparities that undermine health; and a strong public health system. (Center for Policy Analysis 2008)
In December 2008, the Obama Transition Team took the issue of health care reform directly to the American people. People from all walks of life were asked to participate in health care reform house parties and report their findings back to the just-forming Obama Administration. Thousands of people participated in this fact-finding exercise. Findings from this effort have not yet been released.
Equally importantly, there is a need to support a broader public health system as an integral part of reforming the nation’s health. The Prevention Institute (2008) estimates that only 15% of premature deaths are directly attributed to shortfalls in medical care. PRI’s recent report, Reducing Health Care Costs Through Prevention, also concludes that preventive care keeps our population healthier and saves costs by reducing needless preventable illnesses and injuries.
At a time when there is growing recognition that the public’s health is affected by a wide range of factors, there is a unique opportunity to support the viewpoint long advanced by APHA: that population health is largely determined by social and economic policies, which can be directed to benefit the public.
APHA has long advocated for universal coverage for affordable health care as a basic human right. As the United States once again approaches the prospect of a transformative leap to achieve universal coverage for health care, it is valuable to reflect on public health’s strong body of policy articulating the importance of an affordable health care system that covers everyone, with comprehensive benefits, democratic participation to assure that the health care delivery system is responsive and provides appropriate, quality care, and the critical role of public health in all its dimensions in improving the health of the public.
II. Existing APHA Policies and Resolutions
APHA has committed to supporting health care system reforms, including reforms in the coverage and financing of health care, and reforms in the health care delivery system. APHA also calls attention to the importance and impact of the range of public health activities from preventive services to healthier communities to elimination the social and economic inequalities that undermine health.
In 1993 APHA leaders developed 14 Points on Health Reform, described below, that established public health’s essential criteria for reform. This section reviews statements by related organizations, and then illustrates the breadth of existing APHA policies that support the 14 Points.
Policies by Related Organizations
Rekindling Reform elaborated on the 14 Points in the January, 2003, edition of the American Journal of Public Health, focusing on
1. Universal and Equitable Coverage
2. Comprehensive Benefits and Quality Health Care
3. Affordable and Equitable Financing
4. Simplified Administration and Sensibly Organized Work
5. Accountability
6. A Strong Public Health System
APHA Policies: The 14 Points
APHA recognizes and affirms that access to health care is a basic human right. The APHA 14 Points on Health Reform, established in 1993 and reaffirmed in 2000 (Policy #20007), created core principles that health care financing and delivery systems that must address. The present statement does not modify those established 14 Points, but builds on them, citing related APHA policies that further define or enhance each Point.
1. Universal coverage for everyone in the United States.
APHA endorses effective health care reform that covers all residents. Prior comprehensive health care reform statements include support for a:
Also significant are numerous prior APHA health care reform positions that address the importance of coverage for vulnerable and underserved populations:
APHA policies establish support for comprehensive health care benefits, and point to issues of access and expansion of conventional health care benefits needed by individuals and by communities. Policies include specific mention of contraceptives and reproductive health care (#200611), mental health treatment (#9701), dental and oral health (#200117, #6611), affordable prescription drugs (#7810, 20018, 20006), vision rehabilitation (#200312), in-home and community-based long-term care (9005), hospice care (#2000-5), chiropractic care (#8331), and alternative and complementary medicine (#9714)
3. Guaranteed protection against very high health care costs
Toward a Comprehensive Universal National Health Program (#9502) supports a national tax-based single payer system with support for ERISA waivers. Other APHA policy has emphasized protecting health care accessibility and quality in a profit-oriented marketplace (#9702) and support for national standards of accountability for access and quality in managed care (#9615) by standing up for the right of individuals to access health care services through a strong regulatory oversight of public to private health care service conversions.
4. Integration of health care and public health through publicly-accountable mechanisms to assure maximum responsiveness to community needs.
APHA also has a record of support for building and maintaining healthy communities, calling on government other sectors of society to invest in programs and policies that can achieve health at the community level. These include:
5. Clearly identified roles for federal, state, and local government health agencies.
The particular importance of Medicare, entitlement programs and public health coverage to vulnerable populations has been noted in:
The federal and state government role in advocating on behalf of children with special health care needs and their families (#9418)
By calling on the President and Congress to defend and support the Medicaid and Medicare (Maintaining the National Commitment to the Nation's Health #9601)
Promoting Accountability in the Provision of Health and Welfare Services to Persons with Mental Illness (#9604),\
4APHA policies also support the government’s obligation to address social, economic and political determinants of health:
Maintaining the National Commitment to the Nation's Health (#9601) affirms that the health of the people requires a universal national health care policy as well as social and economic policies that foster the health, stability, and general welfare of the population, including resources that are basic to health: affordable housing, a safe and nutritious food supply, a safe, peaceful environment, full employment opportunities for a meaningful role in society, and education and information throughout the life span.
As such, APHA urges the President and Congress to defend and support the Medicaid, Medicare, and federal public health, environmental protection, occupational health and safety programs, and federal housing, food, nutrition, and income maintenance entitlements and programs, as well as voter registration services in all public health agencies.
More recently, APHA supported an Urgent Call for a Nationwide Public Health Infrastructure and Action to Reverse the Obesity Epidemic (#200619) which requires multiple cross-cutting policy recommendations.
Policies also call for strengthening the public health infrastructure including: HIV Surveillance by State Public Health Agencies (#9920)
6. Incentives and safeguards to assure effective and efficient organization and integration of services and a high-quality health system.
7. Fair payment to providers using mechanisms which encourage appropriate treatment by providers and appropriate utilization by consumers.
8. Ongoing evaluation and planning to improve the delivery of health services with consumer and provider participation.
APHA has endorsed public accountability, with adequate data systems for monitoring performance and comparative evaluation and organization and administration by federal, state, and local governments assisted by regional organizations for planning and evaluation (#7018)
9. Inclusion of disease prevention and health promotion programs.
10. Support of education and training programs for all health workers.
11. Affirmative action programs in the training, employment, and promotion of health workers.
12. Non-discrimination in the delivery of health services.
13. Education of consumers about their health rights and responsibilities. In 1970, APHA took an initial step toward development of a rational health system in this country by recommending a "national health care program to include democratically constituted, consumer-majority, policy making bodies at every level of administration.” (#7018)
To update this resolution for the 21st Century, APHA requests that a specific taskforce study existing health reform proposals and make recommendations to ensure that any health system reform provides an adequate infrastructure to support democratic, community input into issues of health care access, quality, resource distribution, and priorities.
14. Attention in the organization, staffing, delivery, and payment of care to the needs of all populations including those confronting geographic, physical, cultural, language, and other non-financial barriers to service.
III. Optimizing Health Reform Policy
Efforts to establish universal coverage for the entire population in the U.S. dating back to the early 1900s have faced serious obstacles. Recent successful national health care reform efforts in the U.S. include federal legislation that created Medicare and Medicaid in 1965, publicly financed programs that cover all eligible residents. Medicare is a federally funded program that covers U.S. residents age 65 and over who have contributed to the cost of the program through payments to the Social Security system, and people with certain health conditions and disabilities. Medicaid is funded by both the federal and state governments, and administered by states. It covers some low-income residents with certain health conditions. Medicaid covers pregnancy for most low-income women, and is the major source of funding for nursing home services. Federal law also created the State Children’s Health Insurance Program, which covers about half of low-income children.
The present financial crisis has renewed interest in and the opportunity to address the health care crises of the under- and uninsured, and unaffordable care. Current proposals vary in methods of financing and coverage, and the degree of change they seek to make to the existing patchwork system. Proposals also incorporate assumption about political factors that could influence the success take into account both fiscal and political projections in designing optimal plans for the American public.
Each system has important implications for meeting APHA’s criteria for reform. APHA should support proposals that can succeed in achieving universal coverage – that is, covers all residents - and is affordable, as well as other critical goals. Such programs must at a minimum strengthen and expand existing public sector, social insurance programs such as Medicare, Medicaid, SCHIP and safety net services (public hospitals, community health centers, and a network of state, county, local and nonprofit health services).
III. Key Public Health Issues in Health Reform
APHA has expressed support for the single payer financing system for decades, including through the 14 Points and in a 1995 policy statement. Under this system, a single payer - the government - pays directly for all health care. This system is widely accepted by Lewin and other analysts (Congressional Budget Office, Government Accounting Office) to be capable of achieving the two important attributes of successful and sustainable health care systems: 1) Universal coverage. Eligibility is guaranteed automatically as a condition of the program, eliminating current private insurance industry practices such as exclusions for pre-existing conditions. Private plans compete by seeking to exclude people who are likely to use health benefits, and who would thus incur a “loss” to the insurance company; or by limiting services and reimbursements to patients. A single payer plan would also achieve: 2) A substantial measure of cost control. This is possible because the government has sufficient economic and political power to negotiate for affordable prices with health care providers, including the pharmaceutical industry. The system eliminates the participation of the thousands of private health insurance plans, and therefore sharply reduces administration costs, estimated at 31% of health care expenditures, many times higher than Medicare or other national systems. (Woolhandler 2003).
Most other industrialized countries employ some form of government mechanism to assure universal coverage and to control costs. All have better coverage and spend less than the U.S. They have health outcomes that are at least as good as the U.S., and in some cases better.
Industries that would lose substantial revenues under a single payer system are politically opposed to it. The private health insurance industry would be sharply curtailed, while the pharmaceutical, hospital supply, and other health-related industries would experience prices more in line with those in the rest of the world. Other opponents include interests who are ideologically or structurally in favor of free market approaches as an alternative to government administration of health care services, which often include large employer groups, and individuals who mistrust the government. Single payer proposals have been portrayed in the past as too sharp a departure from present arrangements (Lake 2007, Geyman 2005). However, single payer legislation has passed in two separate sessions of the California legislature in the last four years. The public and most physicians now express support for a government-financed system like Medicare. (Carroll, Ackerman)
A report prepared by the Institute for Health and Socio-Economic Policy (2009) asserts that implementing a single payer system would create over 2.6 million new jobs--more than the number of jobs lost during 2008--and create an economic fiscal stimulus of $317 billion. The authors concluded that cost savings would exceed the new costs of providing universal coverage for all.
HR 676 of 2009 is the most recent national legislation that builds on the Medicare program to propose a single payer financing system.
V. APHA’s Role in Reform
APHA shares values with many of the groups seeking to fix our ailing health care system. Indeed, its record of support for the inclusion of home and community-based long-term care and other options not traditionally covered by any conventional public or private health plans enables APHA to advocate for enriching many proposals for “universal health care.”
APHA must marshal its forces to articulate and advocate for its long-standing policies. Premier among these is universal coverage for all residents. This is a basic cornerstone of human rights as well as APHA policy. It is essential to the ability of any health system to contribute to improving health, at a cost that is affordable for all payers, including individuals, employers and the government.
Additionally, APHA is uniquely positioned to advocate for the inclusion of public health in the reform policy discussions. By calling for “health reform,” APHA can broaden the policy agenda to include key policy areas that impact Americans’ ability to achieve optimum health. These include:
Action Statements
Therefore the American Public Health Association
Urges Congress and the Administration to enact a program of universal coverage for health care that includes all residents, that is affordable for all payers, including individuals, employers and the government, and that is consistent with APHA policies and principles.
Urges Congress and the Administration to support and enact the First 100 Days Agenda for Health Reform, and to continue its approach to health reform: to strengthen and expand existing public health insurance programs, and to improve the public’s health.
Urges the US Congress and DHHS to consider and adopt the APHA’s 14 principles of health care reform, and the Center for Policy Analysis’ Criteria for Reform.
Urges the DHSS and the CDC to identify multidisciplinary best practice preventive health education practices (e.g. weight management education, diabetes education, asthma education) and recommend they be covered health benefits for all Americans.
Urges the CDC to develop a community health registry as part of the health care information technology initiatives that gathers data on chronic diseases and key determinants of health.
Urges the CDC to endorse an agenda that supports education, policy and practice in addressing the social determinants of health by funding best practices that improve the health of communities.
Urges CDC identify an office within the organization that can oversee evaluation of community health assessments, certificate of need programs and health impact assessment.
Urges Congress to allocate financial and human resources at federal, state and local levels to set up a workgroup in collaboration with professional organizations including, but not limited to, APHA, Association of State and Territorial Health Officials (ASTHO), Council of State and Territorial Epidemiologists (CSTE), and the National Association of County and City Health Officials (NACCHO) to develop a plan and recommendations for developing and evidence-base of effective community health assessment practice.
Urges DHHS to engage in a new era of health care regulatory and participatory oversight including restoration community health planning as a planning and regulatory process that empowers communities to participate in identifying their health care needs, making service providers accountable for meeting them, and evaluating their impact on community health status.
Urges the US Congress and the National Conference of State Legislatures to adopt a legislative strategy that will consider the community health impact of budget decisions and new laws (e.g., zoning, agriculture, water, urban development, economic development, education)
Pledges - and urges membership units and members to engage in the health care reform debate by building and working with coalitions and providing input to guide health care reform policy agendas and advocacy work to protect vulnerable populations and communities and to identify public health initiatives to include in existing reform agendas.
References
Axeen S & Carpenter E (2008) The cost of doing nothing, Why the cost of failing to fix our health system is greater than the cost of reform. New America Foundation November 2008.
Brookings/JTPC: Brookings-Urban Joint Tax Policy Center (2008) An updated analysis of the 2008 presidential candidates' tax plans: Revised August 15, 2008
http://www.taxpolicycenter.org/publications/urlprint.cfm?ID=411749; and
Aug. 28: http://www.taxpolicycenter.org/publications/url.cfm?ID=411750
Brown ER et al. (2008) Nearly 6.4 million California residents lacked health insurance in 2007 – Recession likely to reverse small gains in coverage. UCLA Center for Health Policy Research, Los Angeles, CA.
Carroll A & Ackerman (2003) Support for national health insurance among U.S. physicians: 5 years later. Annals of Internal Medicine, 148(7), April 1, 2008; ABC News/Washington Post, Oct. 9-13, 2003, Associated Press/Yahoo News Poll, Dec. 14-20, 2007.
Center for Policy Analysis (2008) Criteria for Reform, 2008, http://www.centerforpolicyanalysis.org/sitebuildercontent/sitebuilderfiles/compareplanscriteria8-08.pdf
Collins S et al. (2009) Analysis of leading congressional health care bills, 2007-2008:
Part I, insurance coverage. January 2009 (see pp. 29-34, 93-99) http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=777197
Corburn J & Bhatia (2007) Health Impact Assessment in San Francisco: Incorporating the Social Determinants of Health into Environmental Planning. Journal of Environmental Planning and Management, Vol. 50, No. 3, 323 – 341, May 2007
Chavkin W, Rosenbaum S, Jones J & Rosenfield A (2008) Women’s health and health care reform: The key role of comprehensive reproductive health care. Mailman School of Public Health at Columbia University.
Citizens Health Care Reform Working Group (Sept 2006). The health report to the American people. http://govinfo.library.unt.edu/chc/healthreport/healthrep.html
Cohen L et al. (2008) Reducing health care costs through prevention. The Prevention Institute, Oakland CA.
Commission on the Social Determinants of Health (2008) Closing the gap in a generation: Health equity though action on the social determinants of health. World Health Organization. Geneva, Switzerland.
Daschle T, Greenberger S & Lambrew, JM. (2008). Critical: What we can do about the health care crisis. Thomas Dunne Books, St. Martin Press.
Families USA (2008) Empty promise: Searching for health insurance in an unfair market. Washington DC
Geyman JP (2005). Myths and memes about single-payer health insurance in the united States: A rebuttal to conservative claims. International Journal of Health Services, 35(1): 63-90.
Institute for Health and Socio-Economic Policy (2009). Single Payer/Medicare for All: An economic stimulus plan for the nation (version 1.0)
Lake, C (2007). How to talk to voters about health care, December 5, 2007, presentation to the Minnesota Legislature.
The Lewin Group (2008). Cost impact analysis for health care in America proposal final report. Prepared by the Economic Policy Institute. The Lewin Group, Inc.
MedPac (2004). Report to the congress: New approaches in Medicare, Chapter 7 Information Technology in Health Care. June 2004
National Coalition on Health Care (2008) Facts on health insurance coverage. Washington, DC
National Multiple Sclerosis Society (2008) National health care reform principles. NMSS Washington DC.
National Physicians Alliance (2008) Achieving guaranteed, quality, affordable health care for all. Reston, VA
The Rekindling Reform Steering Committee (2003) Rekindling Reform: Principles and Goals January 2003, Vol 93, No. 1 | American Journal of Public Health 115-117.
Woolhandler, S et al. (2003) Costs of health care administration in the United States and Canada, New England Journal of Medicine 349: 768-775.
Tammy Pilisuk, MPH
CHPPD Section
Member, Federal Activism Council
National Multiple Sclerosis Society
Ellen R. Shaffer PhD MPH
Medical Care Section
Center for Policy Analysis
San Francisco Presidio
P.O. Box 29586
San Francisco, CA 94129
This policy statement is supported by the Medical Care Section and the Community Health and Policy Development (CHPPD) Section of the American Public Health Association (APHA).
It aims to respond to the following topics identified as policy gaps by the Action Board and Joint Policy Council (JPC):
- Health reform and the changing role of the public health system
- Public health workforce issues
- Financing options for increasing public health funding
I. Problem Statement
Rationale for Health System Reform
“I take care of an uninsured patient population. Not only am I seeing increased numbers of patients, due to the economic crisis, but patients that have previously had stable medical problems are becoming increasingly less stable related to stress from lack of work and less ability to eat healthfully because of cost. I anticipate an increased incidence of domestic violence, andwomen feeling more "trapped"- and an associated decrease in the availability of programs for assistance... this is all part of things ‘mushrooming.’ “ - Amy Fendrich, M.D. Member, APHA Medical Care Section. Personal communication, February 17, 2009.
The U.S. remains alone among developed nations in failing to provide coverage for health care to all residents. The crisis threatens to become more painful as the economy slows. APHA members are joining with national leaders who are proposing to reform the health system.
An estimated 47 million Americans have no health care coverage (National Physicians Alliance, 2008). There is growing evidence that many of those who have some type of public or private coverage face serious barriers to care, restrictions to allowable benefits, or prohibitive costs (Families USA 2008, Brown et al. 2008). Health care expenditures are increasing at a faster rate than the economy. The New America Foundation has estimated that the US economy lost $207 billion in 2007 because of poor health and shorter lifespan of the uninsured—an amount stated to be the sum total expense of the public cost of providing health care coverage to all Americans (Axeen & Carpenter 2008). In short, the health system is broken because it is not available to everyone. While costs continue to increase, there is no concomitant increase in access to health services or improvement in health outcomes.
Private health insurance plans cover about half the people in the U.S. who are insured, and private funds account for less than half of health expenditures. Most privately insured people obtain insurance based on their employment, and contribute to the cost of coverage. There is no requirement that employers offer health benefits. Private insurance plans vary widely, and increasingly fail to cover basic needs: they may not be affordable, may not cover dependents, may exclude people with certain health conditions or coverage for certain benefits. Employees with job-based insurance can lose coverage if they change jobs, or if employers change the terms of coverage or discontinue it.
In 2008 candidates for president campaigned on proposals for national health reform. Since assuming office, President Obama continues to call for health reform, and leaders in Congress are drafting legislative proposals.
Other groups are looking to join the policy discussion to make sure the needs of their constituencies are considered. Among these, the National Multiple Sclerosis Society's 2008 principles of health care reform (NMSS 2008) addresses seven principles with a focus on individuals with chronic care needs and disabilities. A team from the Mailman School of Public Health developed a set of principles relating to women’s reproductive health (Chavkin et al. 2008)
In 2006, the Citizens' Health Care Working Group convened a series of community meetings that recommended “affordable health care for all Americans” with equitable financing defined as 1) not creating a disproportionate increase in the financial burden on the sick; 2) based on a household’s ability to pay; and 3) sharing the cost among all segments of society. They concluded that government, families, and businesses must be involved in improving health care and that “… [we]need to address the entire health care system,” as well as specific problems in cost, quality, or access…”
The Center for Policy Analysis’ Criteria to Evaluate Health Care Reform (2008) encompasses a broad view of health reform, incorporating the concerns of national public health and women’s groups and emphasizing public health and social justice. It calls for universal, affordable coverage, with fair and stable financing, that controls costs; an accountable delivery system that offers quality, appropriate, accessible and equitable care; eliminating social and economic disparities that undermine health; and a strong public health system. (Center for Policy Analysis 2008)
In December 2008, the Obama Transition Team took the issue of health care reform directly to the American people. People from all walks of life were asked to participate in health care reform house parties and report their findings back to the just-forming Obama Administration. Thousands of people participated in this fact-finding exercise. Findings from this effort have not yet been released.
Equally importantly, there is a need to support a broader public health system as an integral part of reforming the nation’s health. The Prevention Institute (2008) estimates that only 15% of premature deaths are directly attributed to shortfalls in medical care. PRI’s recent report, Reducing Health Care Costs Through Prevention, also concludes that preventive care keeps our population healthier and saves costs by reducing needless preventable illnesses and injuries.
At a time when there is growing recognition that the public’s health is affected by a wide range of factors, there is a unique opportunity to support the viewpoint long advanced by APHA: that population health is largely determined by social and economic policies, which can be directed to benefit the public.
APHA has long advocated for universal coverage for affordable health care as a basic human right. As the United States once again approaches the prospect of a transformative leap to achieve universal coverage for health care, it is valuable to reflect on public health’s strong body of policy articulating the importance of an affordable health care system that covers everyone, with comprehensive benefits, democratic participation to assure that the health care delivery system is responsive and provides appropriate, quality care, and the critical role of public health in all its dimensions in improving the health of the public.
II. Existing APHA Policies and Resolutions
APHA has committed to supporting health care system reforms, including reforms in the coverage and financing of health care, and reforms in the health care delivery system. APHA also calls attention to the importance and impact of the range of public health activities from preventive services to healthier communities to elimination the social and economic inequalities that undermine health.
In 1993 APHA leaders developed 14 Points on Health Reform, described below, that established public health’s essential criteria for reform. This section reviews statements by related organizations, and then illustrates the breadth of existing APHA policies that support the 14 Points.
Policies by Related Organizations
Rekindling Reform elaborated on the 14 Points in the January, 2003, edition of the American Journal of Public Health, focusing on
1. Universal and Equitable Coverage
2. Comprehensive Benefits and Quality Health Care
3. Affordable and Equitable Financing
4. Simplified Administration and Sensibly Organized Work
5. Accountability
6. A Strong Public Health System
APHA Policies: The 14 Points
APHA recognizes and affirms that access to health care is a basic human right. The APHA 14 Points on Health Reform, established in 1993 and reaffirmed in 2000 (Policy #20007), created core principles that health care financing and delivery systems that must address. The present statement does not modify those established 14 Points, but builds on them, citing related APHA policies that further define or enhance each Point.
1. Universal coverage for everyone in the United States.
APHA endorses effective health care reform that covers all residents. Prior comprehensive health care reform statements include support for a:
- A National Program for Personal Health Services (#7018)
- Committee for a National Health Service (#7601)
- Comprehensive universal national health program that supports the goal of a single payer approach (#9502)
- Campaign for universal health care (#20007)
Also significant are numerous prior APHA health care reform positions that address the importance of coverage for vulnerable and underserved populations:
- National insurance program for children (#7408) and for special need children (#9418)
- Health care reform for people with disabilities (#9307) and support for disabilities prevention activities (#9505)
- Improving the health status of American Indians and Alaska Natives (#20015)
- Support for rural health care (#9522)
- Ensuring access to health services for undocumented immigrants (#9401)
- Support for culturally and linguistically appropriate primary care and prevention services (#9616)
- Improving Access to Vision and Eye Health Services for Long-Term Care Facility Residents (#9504)
2. Comprehensive benefits including health maintenance, preventive, diagnostic, therapeutic, rehabilitative, behavioral, palliative, long-term care, and end-of-life services for all types of illnesses and health conditions and all other necessary services to meet patients' total health needs
APHA policies establish support for comprehensive health care benefits, and point to issues of access and expansion of conventional health care benefits needed by individuals and by communities. Policies include specific mention of contraceptives and reproductive health care (#200611), mental health treatment (#9701), dental and oral health (#200117, #6611), affordable prescription drugs (#7810, 20018, 20006), vision rehabilitation (#200312), in-home and community-based long-term care (9005), hospice care (#2000-5), chiropractic care (#8331), and alternative and complementary medicine (#9714)
3. Guaranteed protection against very high health care costs
Toward a Comprehensive Universal National Health Program (#9502) supports a national tax-based single payer system with support for ERISA waivers. Other APHA policy has emphasized protecting health care accessibility and quality in a profit-oriented marketplace (#9702) and support for national standards of accountability for access and quality in managed care (#9615) by standing up for the right of individuals to access health care services through a strong regulatory oversight of public to private health care service conversions.
4. Integration of health care and public health through publicly-accountable mechanisms to assure maximum responsiveness to community needs.
APHA also has a record of support for building and maintaining healthy communities, calling on government other sectors of society to invest in programs and policies that can achieve health at the community level. These include:
- The role of public health in ensuring healthy communities (#9521PP)
- Support for immunization programs (#200023)
- Reducing the rising rates of asthma (#200012)
- Promoting public health through physical activity (#9709)
- Disabilities prevention activities (#9505)
- Reducing health disparities in people with disabilities through improved environmental programmatic and service access (#2004-02)
5. Clearly identified roles for federal, state, and local government health agencies.
The particular importance of Medicare, entitlement programs and public health coverage to vulnerable populations has been noted in:
The federal and state government role in advocating on behalf of children with special health care needs and their families (#9418)
By calling on the President and Congress to defend and support the Medicaid and Medicare (Maintaining the National Commitment to the Nation's Health #9601)
Promoting Accountability in the Provision of Health and Welfare Services to Persons with Mental Illness (#9604),\
4APHA policies also support the government’s obligation to address social, economic and political determinants of health:
Maintaining the National Commitment to the Nation's Health (#9601) affirms that the health of the people requires a universal national health care policy as well as social and economic policies that foster the health, stability, and general welfare of the population, including resources that are basic to health: affordable housing, a safe and nutritious food supply, a safe, peaceful environment, full employment opportunities for a meaningful role in society, and education and information throughout the life span.
As such, APHA urges the President and Congress to defend and support the Medicaid, Medicare, and federal public health, environmental protection, occupational health and safety programs, and federal housing, food, nutrition, and income maintenance entitlements and programs, as well as voter registration services in all public health agencies.
More recently, APHA supported an Urgent Call for a Nationwide Public Health Infrastructure and Action to Reverse the Obesity Epidemic (#200619) which requires multiple cross-cutting policy recommendations.
Policies also call for strengthening the public health infrastructure including: HIV Surveillance by State Public Health Agencies (#9920)
- Reducing youth tobacco use (#9514)
- Public health laboratory services (#9614)
- Integrated vector control (#200013), which asks to strengthen state and national disease surveillance and detection systems and adequately fund public risk communication.
- The Role of Public Health in Ensuring Healthy Communities (#9521) recognized public health agencies as the lynch pins for protecting the public from illness, disease, injury, unnecessary death and disability. These may take the form of research, policy and programs affecting workplace hazards, and safety of air, water, and food, and community development.
6. Incentives and safeguards to assure effective and efficient organization and integration of services and a high-quality health system.
- Coordination of carefor vulnerable populations is emphasized in Linkage of Medical Services for Low-Income Populations with Mental Health, Substance Abuse (#9611)
- Standards of protection, regulatory oversight and enforcement have been standard tools of safeguarding both individual and public health.
7. Fair payment to providers using mechanisms which encourage appropriate treatment by providers and appropriate utilization by consumers.
8. Ongoing evaluation and planning to improve the delivery of health services with consumer and provider participation.
APHA has endorsed public accountability, with adequate data systems for monitoring performance and comparative evaluation and organization and administration by federal, state, and local governments assisted by regional organizations for planning and evaluation (#7018)
9. Inclusion of disease prevention and health promotion programs.
10. Support of education and training programs for all health workers.
- Workforce policies recognize a range of health care providers, and the importance of training, recruitment and retention policies that foster a diverse workforce, well qualified to provide high quality and responsive care (#20013, #20032, #9402, #9414, #2005-12)
- Further, the call for Ethical Restrictions on International Recruitment of Health Professionals to the United States
- (#200616) recognized the regrettable absence of a rational, unified national health system. Noting that this impedes our ability to adopt an “ethical recruitment policy” in the face of a health care marketplace that is growing increasingly dependent on foreign-trained health workers. As such, APHA urged:
- Voluntary adoption of a health industry-wide code of ethics that guides recruitment and employment of health professionals (including unlicensed caregivers) from abroad.
- Expansion of class size for U.S. health professional training programs
- Government subsidies to improve salary scales and working conditions
- Incentives to better distribute health professionals
- Regulations on U.S. government health care services contracts (e.g., for Medicare and research purposes) to abide by a specified code of standards.
11. Affirmative action programs in the training, employment, and promotion of health workers.
- Endorsed in Addressing Hispanic Underrepresentation in the Health Professions (#9613):
12. Non-discrimination in the delivery of health services.
- Principles were endorsed in support for disabilities prevention activities (#9505),
- Improving the health status of American Indians and Alaska Natives (#20015)
- Ensuring access to health services for undocumented immigrants (#9401), and
- Support for culturally and linguistically appropriate primary care and prevention services (#9616)
13. Education of consumers about their health rights and responsibilities. In 1970, APHA took an initial step toward development of a rational health system in this country by recommending a "national health care program to include democratically constituted, consumer-majority, policy making bodies at every level of administration.” (#7018)
To update this resolution for the 21st Century, APHA requests that a specific taskforce study existing health reform proposals and make recommendations to ensure that any health system reform provides an adequate infrastructure to support democratic, community input into issues of health care access, quality, resource distribution, and priorities.
- Proposed health care system reforms for children (#9418) included planning and evaluation with consumer and provider participation and mechanisms to ensure consumer participation in governance and redress of grievances. It also specified consumer education with the appeal that public agencies take the role to inform consumers and providers about individual rights, entitlements, and standards that define quality health care. Additionally, consumer organizations were given a role in assisting families with information and support.
- In 1970, APHA called for a health care system reform financed by combination of federal social insurance and general tax revenues, to insure health care as a social right, and to achieve reasonable equity in paying for it (#7018).
- Eliminating financial and other barriers to care have been affirmed in several prior APHA policies (#9616, #9418, #7018)
III. Optimizing Health Reform Policy
Efforts to establish universal coverage for the entire population in the U.S. dating back to the early 1900s have faced serious obstacles. Recent successful national health care reform efforts in the U.S. include federal legislation that created Medicare and Medicaid in 1965, publicly financed programs that cover all eligible residents. Medicare is a federally funded program that covers U.S. residents age 65 and over who have contributed to the cost of the program through payments to the Social Security system, and people with certain health conditions and disabilities. Medicaid is funded by both the federal and state governments, and administered by states. It covers some low-income residents with certain health conditions. Medicaid covers pregnancy for most low-income women, and is the major source of funding for nursing home services. Federal law also created the State Children’s Health Insurance Program, which covers about half of low-income children.
The present financial crisis has renewed interest in and the opportunity to address the health care crises of the under- and uninsured, and unaffordable care. Current proposals vary in methods of financing and coverage, and the degree of change they seek to make to the existing patchwork system. Proposals also incorporate assumption about political factors that could influence the success take into account both fiscal and political projections in designing optimal plans for the American public.
Each system has important implications for meeting APHA’s criteria for reform. APHA should support proposals that can succeed in achieving universal coverage – that is, covers all residents - and is affordable, as well as other critical goals. Such programs must at a minimum strengthen and expand existing public sector, social insurance programs such as Medicare, Medicaid, SCHIP and safety net services (public hospitals, community health centers, and a network of state, county, local and nonprofit health services).
III. Key Public Health Issues in Health Reform
- Social Determinants of Health
A growing recognition of the social determinants of health, such as clean and safe food, water and air; safety from violence, security in income, nutrition, shelter, and community; unfettered access to clinical preventive services, immunizations and screenings; and disease surveillance all play vital roles in the health of our communities nationwide.
The broadest view has been articulated by the Commission on the Social Determinants of Health 2008: Social justice is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death. These avoidable health inequalities arise because of the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness. The conditions in which people live and die are, in turn, shaped by political, social, and economic forces and policies.
- Health IT
Inefficiencies are inherent in a patchwork system with many layers of administration and redundancies because health care providers and service agencies cannot easily share or exchange information. As a result, calls for bringing health care information technology into the 21st Century have become more popular (MedPac 2004). The Institute of Medicine’s Quality Chasm report (2001) called for new organizational models capable of investing in health information technology (IT); managing new clinical knowledge and skills; designing care processes based on best practices; assembling and deploying multidisciplinary teams; coordinating care; and measuring and improving performance. The development of databases, registries, and tracking systems facilitate monitoring of diseases, risk factors, and other factors needed to assess, plan for, and predict interventions and outcomes. Clearly, investment in IT tools must be part of investing in our health system infrastructure.
- Accountability of health care
Health planning and regulatory oversight have been essential tools in controlling market-driven inefficiencies in health care delivery (Center for Governmental Research 2008). Unlike other industries, in which competition and market forces promote price controls and efficiency, price controls in the health care industry are weak, and often misdirected. Competition in health care has resulted in overcapacity, rather than greater efficiency (i.e. capacity that matches consumer needs) and lower costs for consumers. While not all stakeholders embrace community health planning and regulation, they have been shown to improve performance by supporting planning, supplementing resources, addressing overcapacity, and promoting standards. In Rochester, New York, a long-standing history of community-based planning helped limit the expansion of hospital capacity, and control the diffusion of expensive medical technology to effectively control health care expenditures (Hall & Griner 1993).
- Improving the Population’s Health
“Covering the uninsured and modernizing America’s health care system are urgent priorities, but they are not enough. This nation is facing a true epidemic of chronic disease. An increasing number of Americans are suffering and dying needlessly from diseases such as obesity, diabetes, heart disease, asthma and HIV/AIDS, all of which can be delayed in onset if not prevented entirely. One in 3 Americans—133 million—have a chronic condition, and children are increasingly being affected.
IV. Financing Comprehensive Reform
“The federal government and state and local governments play critical roles across the full range of disease prevention and health promotion activities. First, working together, governments at all levels should lead the effort to develop a national and regional strategy for public health and align funding mechanisms to support its implementation. Second, the field of public health would benefit from greater research to optimize organization of the 3,000 health departments in this nation,45 collaborative arrangements between levels of government and its private partners, performance and accountability indicators, integrated and interoperable communication networks, and disaster preparedness and response. Third, the government must invest in workforce recruitment as well as modernizing our physical
structures, particularly our public health laboratories. And finally, the government must examine its own policies, including agricultural, educational, environmental and health policies, to assess and improve their effect on public health in this nation.” (Obama-Biden Plan to Lower Health Care Costs and Ensure Affordable, Accessible Health Coverage For All)
Health Impact Assessments can call attention to neighborhood conditions, and broader social and economic policies, that directly affect health at the population level. For example, residents, city planners and health departments can call attention to the need for healthy built environments. These require adequate and good quality housing; access to public transit, schools, and parks; safe routes for pedestrians and bicyclists; meaningful and productive employment; unpolluted air, soil, and water; and, cooperation, trust, and civic participation. The Healthy Development Measurement Tool connects public health to urban development planning to achieve a higher quality social and physical environment that advances health. http://www.thehdmt.org/
In addition, APHA must play a key role in advocating for a strong public health infrastructure and a system that improves population health. While often neglected in the past, public health is now frequently referenced by policymakers, both regarding health care delivery system improvements and support for clinical preventive services such as immunizations, and also regarding broader public health functions that safeguard and improve population health, from monitoring and surveillance of health conditions to addressing social and economic inequalities.
APHA has expressed support for the single payer financing system for decades, including through the 14 Points and in a 1995 policy statement. Under this system, a single payer - the government - pays directly for all health care. This system is widely accepted by Lewin and other analysts (Congressional Budget Office, Government Accounting Office) to be capable of achieving the two important attributes of successful and sustainable health care systems: 1) Universal coverage. Eligibility is guaranteed automatically as a condition of the program, eliminating current private insurance industry practices such as exclusions for pre-existing conditions. Private plans compete by seeking to exclude people who are likely to use health benefits, and who would thus incur a “loss” to the insurance company; or by limiting services and reimbursements to patients. A single payer plan would also achieve: 2) A substantial measure of cost control. This is possible because the government has sufficient economic and political power to negotiate for affordable prices with health care providers, including the pharmaceutical industry. The system eliminates the participation of the thousands of private health insurance plans, and therefore sharply reduces administration costs, estimated at 31% of health care expenditures, many times higher than Medicare or other national systems. (Woolhandler 2003).
Most other industrialized countries employ some form of government mechanism to assure universal coverage and to control costs. All have better coverage and spend less than the U.S. They have health outcomes that are at least as good as the U.S., and in some cases better.
Industries that would lose substantial revenues under a single payer system are politically opposed to it. The private health insurance industry would be sharply curtailed, while the pharmaceutical, hospital supply, and other health-related industries would experience prices more in line with those in the rest of the world. Other opponents include interests who are ideologically or structurally in favor of free market approaches as an alternative to government administration of health care services, which often include large employer groups, and individuals who mistrust the government. Single payer proposals have been portrayed in the past as too sharp a departure from present arrangements (Lake 2007, Geyman 2005). However, single payer legislation has passed in two separate sessions of the California legislature in the last four years. The public and most physicians now express support for a government-financed system like Medicare. (Carroll, Ackerman)
A report prepared by the Institute for Health and Socio-Economic Policy (2009) asserts that implementing a single payer system would create over 2.6 million new jobs--more than the number of jobs lost during 2008--and create an economic fiscal stimulus of $317 billion. The authors concluded that cost savings would exceed the new costs of providing universal coverage for all.
HR 676 of 2009 is the most recent national legislation that builds on the Medicare program to propose a single payer financing system.
V. APHA’s Role in Reform
APHA shares values with many of the groups seeking to fix our ailing health care system. Indeed, its record of support for the inclusion of home and community-based long-term care and other options not traditionally covered by any conventional public or private health plans enables APHA to advocate for enriching many proposals for “universal health care.”
APHA must marshal its forces to articulate and advocate for its long-standing policies. Premier among these is universal coverage for all residents. This is a basic cornerstone of human rights as well as APHA policy. It is essential to the ability of any health system to contribute to improving health, at a cost that is affordable for all payers, including individuals, employers and the government.
Additionally, APHA is uniquely positioned to advocate for the inclusion of public health in the reform policy discussions. By calling for “health reform,” APHA can broaden the policy agenda to include key policy areas that impact Americans’ ability to achieve optimum health. These include:
- Building a robust multi-disciplinary health planning infrastructure that guides policy and program development on behalf of our communities.
- Restoring strong regulatory oversight to ensure that any health system reforms work in the best interest of health care consumers. And, as a core value, that the
- Incorporating non-medical social determinants of health (e.g., economic, urban development, agricultural, environmental, housing, zoning, transportation, trade and other policy arenas) into program and policies that support each community’s ability to offer healthy living options to all its residents.
Action Statements
Therefore the American Public Health Association
Urges Congress and the Administration to enact a program of universal coverage for health care that includes all residents, that is affordable for all payers, including individuals, employers and the government, and that is consistent with APHA policies and principles.
Urges Congress and the Administration to support and enact the First 100 Days Agenda for Health Reform, and to continue its approach to health reform: to strengthen and expand existing public health insurance programs, and to improve the public’s health.
Urges the US Congress and DHHS to consider and adopt the APHA’s 14 principles of health care reform, and the Center for Policy Analysis’ Criteria for Reform.
Urges the DHSS and the CDC to identify multidisciplinary best practice preventive health education practices (e.g. weight management education, diabetes education, asthma education) and recommend they be covered health benefits for all Americans.
Urges the CDC to develop a community health registry as part of the health care information technology initiatives that gathers data on chronic diseases and key determinants of health.
Urges the CDC to endorse an agenda that supports education, policy and practice in addressing the social determinants of health by funding best practices that improve the health of communities.
Urges CDC identify an office within the organization that can oversee evaluation of community health assessments, certificate of need programs and health impact assessment.
Urges Congress to allocate financial and human resources at federal, state and local levels to set up a workgroup in collaboration with professional organizations including, but not limited to, APHA, Association of State and Territorial Health Officials (ASTHO), Council of State and Territorial Epidemiologists (CSTE), and the National Association of County and City Health Officials (NACCHO) to develop a plan and recommendations for developing and evidence-base of effective community health assessment practice.
Urges DHHS to engage in a new era of health care regulatory and participatory oversight including restoration community health planning as a planning and regulatory process that empowers communities to participate in identifying their health care needs, making service providers accountable for meeting them, and evaluating their impact on community health status.
Urges the US Congress and the National Conference of State Legislatures to adopt a legislative strategy that will consider the community health impact of budget decisions and new laws (e.g., zoning, agriculture, water, urban development, economic development, education)
Pledges - and urges membership units and members to engage in the health care reform debate by building and working with coalitions and providing input to guide health care reform policy agendas and advocacy work to protect vulnerable populations and communities and to identify public health initiatives to include in existing reform agendas.
References
Axeen S & Carpenter E (2008) The cost of doing nothing, Why the cost of failing to fix our health system is greater than the cost of reform. New America Foundation November 2008.
Brookings/JTPC: Brookings-Urban Joint Tax Policy Center (2008) An updated analysis of the 2008 presidential candidates' tax plans: Revised August 15, 2008
http://www.taxpolicycenter.org/publications/urlprint.cfm?ID=411749; and
Aug. 28: http://www.taxpolicycenter.org/publications/url.cfm?ID=411750
Brown ER et al. (2008) Nearly 6.4 million California residents lacked health insurance in 2007 – Recession likely to reverse small gains in coverage. UCLA Center for Health Policy Research, Los Angeles, CA.
Carroll A & Ackerman (2003) Support for national health insurance among U.S. physicians: 5 years later. Annals of Internal Medicine, 148(7), April 1, 2008; ABC News/Washington Post, Oct. 9-13, 2003, Associated Press/Yahoo News Poll, Dec. 14-20, 2007.
Center for Policy Analysis (2008) Criteria for Reform, 2008, http://www.centerforpolicyanalysis.org/sitebuildercontent/sitebuilderfiles/compareplanscriteria8-08.pdf
Collins S et al. (2009) Analysis of leading congressional health care bills, 2007-2008:
Part I, insurance coverage. January 2009 (see pp. 29-34, 93-99) http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=777197
Corburn J & Bhatia (2007) Health Impact Assessment in San Francisco: Incorporating the Social Determinants of Health into Environmental Planning. Journal of Environmental Planning and Management, Vol. 50, No. 3, 323 – 341, May 2007
Chavkin W, Rosenbaum S, Jones J & Rosenfield A (2008) Women’s health and health care reform: The key role of comprehensive reproductive health care. Mailman School of Public Health at Columbia University.
Citizens Health Care Reform Working Group (Sept 2006). The health report to the American people. http://govinfo.library.unt.edu/chc/healthreport/healthrep.html
Cohen L et al. (2008) Reducing health care costs through prevention. The Prevention Institute, Oakland CA.
Commission on the Social Determinants of Health (2008) Closing the gap in a generation: Health equity though action on the social determinants of health. World Health Organization. Geneva, Switzerland.
Daschle T, Greenberger S & Lambrew, JM. (2008). Critical: What we can do about the health care crisis. Thomas Dunne Books, St. Martin Press.
Families USA (2008) Empty promise: Searching for health insurance in an unfair market. Washington DC
Geyman JP (2005). Myths and memes about single-payer health insurance in the united States: A rebuttal to conservative claims. International Journal of Health Services, 35(1): 63-90.
Institute for Health and Socio-Economic Policy (2009). Single Payer/Medicare for All: An economic stimulus plan for the nation (version 1.0)
Lake, C (2007). How to talk to voters about health care, December 5, 2007, presentation to the Minnesota Legislature.
The Lewin Group (2008). Cost impact analysis for health care in America proposal final report. Prepared by the Economic Policy Institute. The Lewin Group, Inc.
MedPac (2004). Report to the congress: New approaches in Medicare, Chapter 7 Information Technology in Health Care. June 2004
National Coalition on Health Care (2008) Facts on health insurance coverage. Washington, DC
National Multiple Sclerosis Society (2008) National health care reform principles. NMSS Washington DC.
National Physicians Alliance (2008) Achieving guaranteed, quality, affordable health care for all. Reston, VA
The Rekindling Reform Steering Committee (2003) Rekindling Reform: Principles and Goals January 2003, Vol 93, No. 1 | American Journal of Public Health 115-117.
Woolhandler, S et al. (2003) Costs of health care administration in the United States and Canada, New England Journal of Medicine 349: 768-775.
tpilisuk |
Latest page update: made by tpilisuk
, Feb 19 2009, 2:37 PM EST
(about this update
About This Update
Priti, thanks for posting. This is the "final" document that was submitted to APHA Joint Powers Committee. It should not be edited unless we get specific instructions. However, I did remove my home addess as I don't want that on the web.
- tpilisuk
6 words deleted view changes - complete history) |
|
Keyword tags:
None
More Info: links to this page
|
There are no threads for this page.
Be the first to start a new thread.
