In my last post (16 December 2009), I discussed the public health provisions in the Senate’s health reform legislation. Now that the Senate has enacted its bill, the two versions must be reconciled in conference. Most of the prevention and wellness provisions would achieve similar objectives, though the Senate version is more comprehensive. But there are important differences in the two versions regarding other aspects of interest to public health advocates and practitioners. (In a subsequent post, I plan to address the programmatic differences in more detail.)
In this post, I want to focus on two features of the House bill (H.R. 3962) that I will argue are superior to the Senate version—the emphasis on improving the public health infrastructure and the funding mechanisms. State and local public health departments will be strengthened if these two features are adopted in the reconciliation process.
Public Health Infrastructure
As noted in the previous post, the Senate’s bill contains relatively little that would improve the deteriorating infrastructure of public health systems. In contrast, the House bill explicitly addresses the problem in Subtitle F—Core Public Health Infrastructure.
Section 3161 of H.R. 3962 requires the HHS Secretary to make an award to each state health department (SHD) to address core public health infrastructure needs. Importantly, the legislation mandates that the money can only be used “to address core public health infrastructure needs.” The Secretary may also make competitive awards to state, local, and tribal health departments for similar purposes.
Section 3171 defines core public health infrastructure around the structural characteristics of delivering public health services. Specifically, the funds must be allocated to: “workforce capacity and competency; laboratory systems; health information, health information systems, and health information analysis; communications; financing; other relevant components of organizational capacity; and other related activities.”
Improving the core public health infrastructure is a critical need. Without federal funds, few states, and even fewer localities, are in any fiscal condition to address infrastructure needs. It is undeniable that the existing public health infrastructure is inadequate to meet the myriad challenges practitioners confront.
As part of a recent CDC project, I had occasion to interview at a local health department (LHD) that was once one of the nation’s premier public health venues. When I went to the interview, the lack of investment in the infrastructure was appalling. The inside of the building was dark and dreary (“Once upon a midnight dreary….”), with little overhead lighting, doors and walls that hadn’t been painted in decades, and no obvious public health activity. I conducted one of the interviews in a room with peeling paint, wallpaper that was shredded, and furniture that was about my age. It was, in short, a depressing place just to enter, let alone work. How can high quality professionals be recruited to work in this environment? How can the public believe that adequate public health services are being provided?
In sum, the investment in core public health infrastructure is a necessary pre-condition for effectively implementing the legislation’s prevention objectives. This provision, which does not appear in the Senate bill, must be incorporated into the final legislation.
One of the deficiencies in the Senate’s version is that funding is either not specified or would be diverted from other sources. To correct this deficiency, the House bill creates a Public Health Investment Fund in Section 2002. Subject to deficit neutrality (a potentially serious constraint), the House version would deposit, as new funding, $4.6 billion in FY 2011, rising to $9 billion in FY 2015. Further, the legislation specifies that funding shall be authorized and appropriated for such activities as community health centers, the national health service corps, primary care education, and nursing workforce development.
The differences are not just semantic. Under the House bill’s language, HHS is required to spend funds on specified public health activities. But under the Senate’s less prescriptive terms, the prevention and other public health programs could be optional, i.e., just symbolic of what Congress would like to achieve if funds becomes available.
Consider, for example, how the two bills treat medical residency training programs that would enhance primary care delivery to underserved populations. Under the Senate bill, the Secretary “may make grants” for such programs. In contrast, Section 2214 of the House bill states that the Secretary “shall establish a program for the training of medical residents in community-based settings….” Funding for the program is to be allocated from the newly created Public Health Investment Fund.
Likewise, the funding for the public health infrastructure grants “will be expended only to supplement, and not supplant, non-Federal and Federal funds otherwise available to the entity for the purpose of addressing core public health infrastructure needs.” The House bill further requires states to maintain the non-federal expenditure at the level provided in the previous fiscal year. As a result, the House bill’s funding language seems to create a duty to allocate the funds as specified, and hence is preferable to the Senate’s version.
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