A Tale of Two Systems – The shortchanging of public health


Bob Hughes, Former President & CEO

We have two health systems in this country. One – our health care system – is anchored in medical treatment delivered one patient at a time. The other – our public health system – promotes health and prevents disease in our neighborhoods, communities, and nation. Both health care and public health are crucial to overall health, yet these two systems have followed sharply different trajectories over the past 50 years. Health care has thrived. It’s almost one-fifth of the economy despite its severe shortcomings in quality, cost, and access. Public health has struggled overall. Even with moments of shining success, the underlying infrastructure has been under-resourced and under-appreciated for years.

The pandemic came along, and like a national stress test, it revealed our anemic public health system and put its weaknesses in stark relief – decades of disinvestment, inadequate staffing, outmoded equipment, copy machines masquerading as information systems, and a disjointed patchwork of financing and organizations.

I have been involved in public health throughout my career. My academic training was in public health. I worked on responding to toxic waste threats in Memphis and was involved in the aftermath of a closed U.S. Public Health Service Hospital in Seattle (yes, public health used to have its own hospitals). I was in San Francisco when the city developed a unique community-based system of care for patients with a new infectious disease, HIV. I was fortunate to join outstanding colleagues at Robert Wood Johnson Foundation on several public health issues – most notably reducing tobacco use. And I was a board member of a local public health agency in New Jersey. So, it is painful to see public health underperform at a time when it is most needed.

The history of financing, staffing, and institutional infrastructures of the two systems explains the level of preparedness for the pandemic. The health care system consists of a constellation of organizations, mostly private sector, in insurance, pharmaceuticals, and care delivery that have thrived over past decades, while the public health system, mostly public agencies, has found it consistently challenging to get adequate funding. Public health is often taken for granted – we don’t think about clean water, safe food, breathable air, and communicable disease testing and surveillance until they aren’t there and we’re in dire need. And we don’t think about the professional expertise, equipment, laboratories, information systems, and staff needed to vigilantly prevent disease and respond to outbreaks. Only when a large-scale public health emergency occurs does attention and public health system strengthening occur, as happened after the 9/11 attacks. But over time, interest and support decline, and funding gets cut or shifted to other priorities and staffing is reduced. As a result of these long-term trends, health care spending dominates national health expenditures. A recent estimate shows that the nation now spends $13 per person on public health, compared to $11,000 per person on medical care; this even though, historically, public health has contributed significantly more to increased life expectancy than medical care.

With COVID-19 shining a national spotlight on public health, it’s time we had a real conversation about this issue, but one that involves understanding what it really is, why it’s necessary, and how to prioritize its importance. We struggle with this topic, as a nation and a state, and as a result, we don’t have adequate infrastructure in place. We’re in a pandemic – our biggest public health emergency, and we’re failing.

In Missouri, public health system funding is lower than most other states, fragmented, and varies widely by county. State public health funding per capita from general revenue is near the bottom of all states. Federal public health funding comes to the state from an alphabet soup of categorical programs. Some of these funds then are distributed to 114 autonomous local public health agencies (LPHAs). LPHAs in each county have different governance structures (boards, county commissioners) and many different funding sources (mil tax, county budget, fees, etc.). The result is an under-funded, under-staffed, and under-coordinated system with wide disparities in services and support – more than a 20-fold difference in public health funding per person across Missouri counties. Let me remind you, this is the system we turn to for effective state, regional, and community prevention of COVID-19.

I hate to state the obvious, but we’ve got to do better, and there is much to do. Missouri’s public health community has recognized the need for fundamental change and has come together to work on transforming the system over the past few years. The pandemic has now forced an opportunity upon us, and we should come together to build on this work and push for faster and bolder change:

  • We need to recognize that public health is fundamentally an essential government responsibility. Our nation’s public health law places primary responsibility on the states, even though states rely heavily on federal funding. We need to acknowledge and trust the expertise of the public health workforce. Combatting and preventing the spread of infectious disease should not be political.
  • As we continue to ramp up our public health COVID-19 response in Missouri, we must think of both the short-term needs and revamping the system for the long term.
  • We should move toward a coordinated system of state, regional, and local public health agencies based on the public health needs of the population.
  • We need to build solid and enduring relationships between the two systems – health care and public health – in communities across the state. Strengthening existing connections between public health agencies and health care institutions like hospitals, federally qualified health centers, and nursing homes provides a promising path forward.

Health is both individual and collective. Missouri needs strong public health and health care systems that work together. We have shortchanged public health, preventing it from reaching its full potential and effectively serving all of us. It’s time we make the tale of two systems one that results in better health care and better prevention, now and in the future.