Swimming upstream _patient_protection_and.2

LWW/JPHMP PHH200276 January 13, 2011 17:21 Char Count= 0

Swimming Upstream? Patient Protection andAffordable Care Act and the Cultural Ascendancyof Public Health

Kenneth DeVille, PhD, JD; Lloyd Novick, MD, MPH

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �

After months of intense political infighting andwidespread public interest and commentary, PresidentBarack Obama signed the Patient Protection and Af-fordable Care Act (PPACA) into law on March 23, 2010.1

The law has been applauded by supporters, and at-tacked by critics, as the most comprehensive publichealth care reform in US history. Such attention is notmisplaced. Its ultimate impact may very well rival thatof Medicare and Medicaid passed more than 40 yearsago.2 PPACA’s scope includes provisions aimed at in-creasing access to medical care, introducing cost con-tainment mechanisms into the public payer system (ie,Medicare and Medicaid), and reforming private insur-ance. As importantly, PPACA does not focus solely onphysician-provided medical care to individual patients.Instead, the statute is suffused with provisions thatpromise to elevate the status of, and national commit-ment to, disease prevention, wellness promotion, andpopulation-based interventions. Such an approach isnot surprising. After all, Barack Obama’s 2008 “Planfor a Healthy American” boldly declared that cover-ing the uninsured was not enough: “Simply put, in theabsence of a radical shift towards prevention and pub-lic health, we will not be successful in containing thecosts or improving the health of the American people[emphasis added].”3

PPACA’s dramatic inclusion of traditional publichealth staples and doctrines has led executive directorof the American Public Health Association, Georges C.Benjamin,4 to declare that “we are at a transformativemoment in our social history. . .health reform providesus the opportunity to reshape the way we care for our-selves by not only expanding access to health servicesbut shifting away from our ‘sick care’ system.” Simi-larly, Congressman Jim McDermott5 has observed thatthe public health provisions of PPACA “indicate a move

J Public Health Management Practice, 2011, 17(2), 102–109

Copyright C© 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

toward making our system give priority to ‘health care’rather than ‘sick care.”’ Koh and Sebelius6 of the De-partment of Health and Human Services forecast thatPPACA “will usher in a revitalized era for preventionat every level of society.”(p1296)

These comments and others like them suggest thatPPACA has positioned the United States on the brink ofa profound social change with respect to: (1) the “cul-tural authority” of public health and (2) the ways inwhich Americans and their government view and pro-mote “health.” It is true that the passage and provisionsof PPACA send an undeniable signal that the dialogueregarding health in the United States has shifted in veryreal ways. PPACA and its provisions may in fact proveto the turning point, which both signals and nurturesthe growing cultural authority of public health profes-sionals and academics. That result is far from guaran-teed and a number of factors will influence whether thenear future will bring progress, or regress.

● Public Health Practice or Medical Care?

While the dividing line between public health practiceand medicine is often indistinct, the classic definitionis frequently drawn from Winslow,7 who characterizedpublic health as the following: . . . the science and artof preventing disease, prolonging life, and promotingphysical health and efficiency through organized com-munity effort for the sanitation of the environment, the

Author Affiliations: Department of Bioethics and Interdisciplinary Studies,

Adjunct Department of Public Health, Brody School of Medicine (Dr DeVille), and

Department of Public Health, Brody School of Medicine (Dr Novick), Greenville,

North Carolina.

The authors thank Cynthia B. Morrow, MD, MPH and Leslie M. Beitsch, MD,

JD for their insightful comments.

Correspondence: Kenneth DeVille, PhD, JD, Professor, Department of

Bioethics and Interdisciplinary Studies, Adjunct Department of Public Health,

Brody School of Medicine, Greenville, NC 27858 ([email protected]).

102

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.


Swimming Upstream? ❘ 103

control of community infections, education of the indi-vidual in principles of personal hygiene, the organiza-tion of medical and nursing services for the early diag-nosis and prevention of disease, and the developmentof the social machinery to assure everyone a standardof living adequate for the maintenance or improvementof health.(p30)

Ordinarily, public health practice focuses on pre-ventive rather than curative approaches, on a popu-lation rather than on an individual basis. It is clear,though, that this dividing line is artificial and per-meable. Physicians in medical practice often offerpreventive as well as curative care, and public healthpractitioners sometimes provide curative treatments toindividual patients. The key inquiry for this discussionis not so much which practitioners provide health carebut rather from what perspective are health questions inpolicy and practice addressed—from the public health,or the individual medical care, model—and whetherthe tendency toward one approach or the other isevolving.

● Prevention and Wellness Provisionsin PPACA

In that it purports to improve the health of the nation,the PPACA of course might be viewed as a public healthdocument. The framers of the act include a wide arrayof substantial and specific measures aimed at furtheringthe public health approach to wellness and prevention.8

Only a representative sampling is required here. One setof provisions requires coverage of preventive servicesin the clinical setting. Newly issued group-health andinsurance-plan policies (included employer-providedinsurance) are prohibited from requiring cost-sharing(mainly co-payments) on a wide range of screening andpreventive medical care measures.9

Mandated coverage includes measures with an“A” or “B” rating from the US Preventive ServicesTask Force; immunizations10; Health Resources andServices Administration (HRSA) sanctioned preven-tive care screenings for infants, children, and ado-lescents; and certain HRSA-endorsed screening forwomen.11 PPACA also eliminates co-payments on aclass of preventive services for Medicare and Medi-caid recipients.12 Under Medicare, providers will bereimbursed for annual wellness visits during whichcomprehensive “personalized prevention plans” willbe created.13 Another PPACA provision allows employ-ers who provide group health insurance to give theiremployees discounted premiums if they participate inwellness programs.14 Employers will be required to pro-vide a break time for nursing mothers for 1 year after

delivery,15 and chain restaurant and vending machinecompanies must post nutritional content of all menuitems.16

On a larger scale, PPACA establishes a “Preventionand Public Health Fund” under the Department ofHealth and Human Services to support public healthprograms, including research, education, screenings,and immunization. The fund was provided an initialappropriation of $500 million with increasing appro-priations thereafter.17 The legislation created a NationalPrevention, Health Promotion and Public Health Coun-cil, chaired by the surgeon general to coordinate fed-eral wellness and health promotion activities and toadvise the president on the most pressing public healthproblems.18 The Department of Health and Human Ser-vices is required to initiate a broad-based educationprogram focused on prevention, and health plans willbe required to develop ways to collect data, evaluatethem, and report how health outcomes can be improvedby preventive measures and quality improvement ac-tivities. PPACA authorizes the creation of loan repay-ment programs specifically designed to increase thepublic health workforce. Under the rubric of “CreatingHealthier Communities” PPACA authorizes Congressto sponsor grants at the state level to aid public healthagencies in data collection, education, screening, andtreatment in a wide range of areas and populations. Fi-nally, PPACA will require data collection and analysisto identify health disparities.

● Prevention and Population Health: Has theTime Come?

The sheer number these and other PPACA provi-sions signal an unprecedented appreciation for publichealth–related remedies and philosophy. The fact thatmany of the prevention provisions of PPACA receivedbipartisan support while other aspects of the act werebitterly contested also suggests at least a partial changein political consciousness when it comes to legisla-tive support for the public health approach. But mixedsignals abound, and the question of the depth andthe staying power of the public health mentality-shiftremain.

As a practical matter, the ultimate impact of the pub-lic health provisions in PPACA will depend heavilyon the implementing regulations that must be draftedby the relevant agencies and the degree to which fu-ture appropriations support the apparent promise ofthe legislation. In “Restoring Health to Health Reform,”Jacobson and Gostin19 applaud the historic importanceof PPACA but sound several notes of caution. Perhaps,most importantly, the real world impact of the pro-visions will depend on future appropriations, few of



104 ❘ Journal of Public Health Management and Practice

which are guaranteed. While grants to state and lo-cal public health organizations are authorized by thePPACA, effectiveness of the program will depend onwhether these future dollars materialize. The creationof the Prevention and Public Health Fund potentiallyrepresents the largest infusion of capital into the pub-lic health infrastructure in U.S. history. Some publichealth advocates were disappointed to discover, how-ever, that nearly half of the first year’s $500 millionallocation was diverted to funding health professionsprograms, rather than to activities that serve more di-rectly population-health concerns. Jacobson and Gostinnote that PPACA provides loan repayment programsto buttress the public health workforce, but lament thatthe legislation “otherwise does not provide sustainableand scalable resources to revitalize the public healthstructure” at the state and community levels. Similarly,Jacobson and Gostin are sensitive to the scant atten-tion devoted in PPACA to reducing social disparitiesthat affect health. Similarly, the legislation’s attack onhealth disparities seems limited to targeted attemptsto changing lifestyle and health behaviors at the indi-vidual or community level through a series of grant-funded initiatives. It does not acknowledge, implicitlyor explicitly, the importance of developing strategiesto influence the social determinants of health. There isa growing recognition that social determinants exert apowerful influence on the comparatively poor state ofhealth in the US compared to other industrialized na-tions. Our willingness to implement policies to affectthese determinants is absent in this legislation, in con-trast to certain European countries, as will be discussedlater.

As a result, Jacobson and Gostin conclude that de-spite its extensive concern for prevention and wellness,“PPACA takes the existing system as a given and doeslittle to change the fundamental dynamic of how publichealth is organized, financed, and delivered.”19(p86)

● Swimming Against the Current?

While PPACA does boast a prominent preventiveagenda, realization of a broad-based public health ap-proach may require swimming upstream against thecurrents of US history, contemporary US culture, andexisting political realities. Unlike Europe, Canada, Swe-den, Finland, and the UK, the public policy environ-ment in the United States may slow implementationof the preventive initiatives pioneered in PPACA anddelay indefinitely the acceptance of more expansiveand sophisticated public health visions. Growing in-equalities in income and wealth combined with Amer-icans’ generally and deep-seated negative attitudes to-ward the role of government, do not provide fertile

soil for an activist and forward-looking public healthagenda. Beauchamp20 recognizes that cultural factorsoften translate into practical barriers to governmentprotection of the health and safety of the public? Thedominant language of American political discourse,Beauchamp observes, has long been individualism,does not support for the benevolent restriction of vol-untary conduct. Government prescriptions of life-stylechoices, so-called public health paternalism, remain ananathema in many regions of the United States. Oneprovision of PPACA requires chain restaurants to pro-vide nutritional content for food sold to customers, anarea of regulation still viewed with special suspicionby many US citizens. One of the authors (LN) servedpreviously as commissioner of health for a county inupstate New York. Frequently he was intimately in-volved in contentious discussions with county legisla-tors who vehemently contended that indoor smokingprohibitions were harbingers of “telling us what to eatat fast-food establishments.”

Jonathan Oberlander21 has ruefully observed that “Inthe United States, the more desirable health care reformis on substantive grounds, the less politically feasible itis.” The history of motorcycle legislation in the UnitedStates seems to exemplify Oberlander’s observationand lament. Despite overwhelming evidence that oper-ator and passenger helmets reduce deaths and injuries,they are currently required in only 20 states.22 Federalefforts, over the last 3 decades, to encourage states toenact these laws have failed, and, where such laws ex-isted, motorcycle advocacy groups have been broadlysuccessful in repealing them. Jones and Bayer23 reason,understandably, that this history raises troubling ques-tions about the realistic possibility of implementing athoroughgoing culture of public health that relies heav-ily on government to protect individuals from theirown choices, even in the face of strong evidence thatthese behaviors result in higher levels of morbidity andmortality.

The cold realpolitik truth is that the funding andimplementation of the provisions of PPACA will de-pend far more on the breadth, depth, and durationof public support than on the well-meaning, scientif-ically verified recommendations and exhortations ofpublic health authorities and academics. Attacks onPPACA public health provisions have already begun.The Johanns Amendment (SA 4596), offered even be-fore the fall elections of 2010 for example, proposedto eliminate nearly all of the funding for the Preven-tion and Public Health Fund of PPACA.24 Although theJohanns Amendment ultimately failed, it is emblem-atic of the inherent vulnerability of PPACA’s preventioninitiatives.

Moreover, it is axiomatic that the conditions underwhich public health initiatives will flourish or wither




are directly related to the political leanings of the par-ticular government currently in power. The vicissitudesof governmental change, especially in the United States,aggravate this reality. International comparisons areinstructive. Consider Canada. Two provinces, Quebecand British Columbia, were early leaders in champi-oning broader concepts of health. Later governments,dominated by political conservatives, downplayed ofpolicies and programs specifically designed to enhancethe population’s health and health promotion.25 Thedramatic shift in power from Democrat-to-Republicanin the 2010 US mid-term congressional elections willundoubtedly affect the degree to which a consistentpublic health approach is pursued at the federal level.Observers doubt that an outright repeal of PPACA isforthcoming, however, Republican leaders seem poisedto blunt the impact of the legislation by failing to fundwhat they view as objectionable provisions.26 It is un-clear at this point how this strategy will affect the publichealth provisions of PPACA.

In contrast, countries with ideologically consistentgovernments have typically been able to stay-the-course in advancing and developing coherent publichealth policy agendas, especially when the underlyingsocial culture is supportive of such approaches. Theapparent results are arresting. Sweden, for example,boasts extraordinarily low levels of infant and child-hood mortality from injury.27 Swedish life expectancyis ninth highest in the world. These health successeshave been achieved even though the gross domesticproduct per capita is relatively low, 17 of 30 among eco-nomic cooperation and development nations.27 Signifi-cantly though, Sweden has low levels of child poverty,low unemployment and very high levels of public so-cial expenditure. Income inequalities remain low.28 Inaddition, social welfare policies implemented in Swe-den during the 1920s have long been institutionalizedinto Swedish government and internalized by Swedishsociety. This orientation has enabled Swedish publichealth officials and the population, to be receptive tonew and broader perspectives, developments and in-novations in health promotion. In the US, activities ofpublic health agencies and social welfare policies havebeen artificially compartmentalized undermining coor-dinated attempts to address the social determinants ofhealth.

Raphael suggests that public health has been charac-terized by 2 dominant models.27 The first, the traditionalmodel (represented as well by PPACA) focuses on biol-ogy, controlling contagious diseases and managing riskbehaviors and factors including weight, diet, tobaccouse, cholesterol levels, and sexual practices. The second,more recent, model focuses as well on what has becomeknown as the “social determinants” of health. This viewof health promotion holds that the health and illness of

populations are affected not only by medical care andlifestyle choice but also by a wide array of social factors,including income, housing, education, human rights,and social status and income disparities. According tothis line of analysis “The stark fact is that most diseaseon the planet is attributable to the social conditions inwhich people live and work.”29(e445) While individualhealth can sometimes be traced fairly directly to tra-ditional biomedical causes, population health is corre-lated to the social determinants of health. The socialdeterminants of health approach to population healthhas found far more receptive homes in those culturesand governments that have a long-standing, stable,and consistent commitment to public health in general.Again drawing on the Swedish example, Welfare in Swe-den: The Balance Sheet for the 1990’s (2002) highlights theconcern of the Swedish government for general, over-arching societal well-being. Welfare in Sweden focusesits attention and commitment on broad social determi-nants, which are increasingly viewed as the foundationof health inequalities.30 A focus on social determinantsalso distinguishes the Swedish approach from publichealth provisions in PPACA, which emphasize almostsolely important, but limited, preventive health mea-sures, clinical preventive services, health behaviors andcommunity health initiatives.

Similar to Sweden, but in contrast to the UnitedStates, the United Kingdom has demonstrated a long-standing concern with class-related inequality. TheBlack Report (1980) revealed that despite a generationof universal medical care, health inequalities remainedor actually increased.27 The Black Report and similarrecommendations were ignored for nearly 2 decades.Until 1997 when the new Labour Government imple-mented a series of policy recommendations embracingboth models of public health improvement: (1) address-ing the social determinants and (2) risk behaviors andfactors.31 Britain’s first Minister for Public Health wasappointed and according to a Labour Party manifesto:“A new minister for public health will attack the rootcauses of ill health, and so improve lives and save NHSmoney. Labour will set new goals for improving theoverall health of the nation, which recognise the im-pact that poverty, poor housing, unemployment and apolluted environment have on health.”32 Similarly, Re-ducing Health Inequalities: An Action Report (1999), pro-duced by the Department of Health in the UK, includedspecific policies on health determinants of living stan-dards, education, employment, housing, and buildinghealthy communities.33 In the white paper Saving Lives:Our Healthier Nation, the UK government issued themost explicit approach taken by any European govern-ment to improve public health.34 Prime Minister TonyBlair, in its forward, lauds the importance of exercise,eating properly, and not smoking, and a strategy for




population prevention was outlined including a con-tract to reduce the death rate from heart disease andstroke among people younger than 65 years by at leastone-third.35

What happened next in the United Kingdom is mostinstructive and illustrative of the changing fortunesof public health, even in a country that has tradi-tionally been receptive to such concerns. By 1999, thenewly created position of Minister for Public Health,initially filled by Tessa Jowell, was downgraded tothe lowest ministerial rank: parliamentary under sec-retary, diminishing its stature and influence.36 Jow-ell’s successor carried neither the rank nor the back-ground in social policy to spearhead the ambitiousagenda articulated merely 3 years previous.37 Con-currently, enthusiasm and commitment seemed towane for the health inequalities reduction program.As McKee31 points out the “government and its healthdepartment have yet to show that tackling inequali-ties in health are as important as reducing NHS wait-ing lists and developing specialty care for people withcancer, heart disease, and mental illness.” Thus, pub-lic health is frequently assigned lower priority even insingle-payer systems in which healthcare and healthpromotion might be more easily integrated.

The parallels with the future role of prevention inthe US health care reform are important. Consider thestop-and-start progress of public health reform in theUnited Kingdom, a country, which, unlike the UnitedStates, is characterized by a long tradition of publichealth concern and sensitivity to the social determi-nants of health. Currently in the United States, broad-based public health concerns cannot compete withsociety’s concern with the status of individual medi-cal care or the advocacy of the health-related indus-tries of insurance, hospitals, and pharmaceutical com-panies. What will be the staying power of even theprevention initiatives when turbulence arises with themany medical care issues that will be engendered byPPACA?

● The Practical Implications of “CulturalAuthority” and the Battle for Heartsand Minds

As noted, the promise of PPACA can only be fulfilledif the regulations that will actually operationalize itsprovisions embody a broader vision of health care, dis-ease prevention, wellness promotion, and population-based remedies. Both the content of the regulations andthe amount and placement of future funds will dependon what might be labeled as the “cultural authority”of public health, and the degree to which Americans

and their government view “health care” as somethingbroader than merely medical care for sick individuals.

In the United States, “medical care” and physicianshave become associated with individual patients, cures,and focused scientific remedies. In contrast, “publichealth” has been associated with population-health,prevention, and the remediation through policy and ed-ucation of unhealthy conditions.38 For a variety of rea-sons, physicians were said to have achieved “culturalauthority” in the first one-third of the 20th century. Thiscultural authority, as well as growing technical and sci-entific competence, played a key role in the Americanpublic’s acceptance of the use of physicians to providetheir medical care.39 As importantly for this discussion,the medical profession’s cultural authority assured thepublic’s acceptance of the medical profession’s opin-ion and perspectives on disease, health, health care,and policy. As a result, physicians not only dominatedhealth care delivery but also “enjoyed a correspond-ing power in the domain of ideas.”40(S26) The success ofphysicians in establishing this social legitimacy and cul-tural authority incidentally undercut the ability of otherhealth professionals and perspectives to influence pub-lic opinion, governmental action, concepts of health,and health care.

The public health perspective in the United Stateshas matured scientifically and conceptually over thelast century, but it has heretofore failed to command theattention or respect accorded to physician-driven sci-entific medicine. But, there are signs of change. PPACAafter all, includes a far larger number of public health–related initiatives than did the failed Clinton HealthCare plan of 15 years ago. Recent historical factors andindicators have undoubtedly broadened the public’sview of health and health policy. A growing under-standing and acceptance by the public of the behav-ioral and environmental determinants of health hasincreased public support both for regulation and forvoluntary, culturally driven lifestyle changes. Nearly 4decades of rising medical costs and expenditures haveincreased the interest in and commitment to preventivehealth measures in general. Finally, public awareness ofthe multiple threats of both bioterrorism and pandemicflu in the last decade have highlighted the insights andtools that public health theorists and professionals canoffer the country.40

Despite these indicators suggesting a consciousnesschange in Americans’ attitude toward public healthactivity and philosophy, there are reasons to believethat the transformation, while underway, will remainat least incomplete for some time. By almost anyestimation, the public health approach is still atodds with the still widespread and resilient notionsof individualism, personal responsibility, and limitedgovernment among many in the United States. The rise




of the medical profession and the medicalized view ofhealth were based partially on the US public’s confi-dence and attraction to the biomedical approach to un-derstanding and treating sickness and disease. This ap-peal has persisted long after it has become clear thatthe purely biomedical approach to disease and illnesscannot address fully the reality of environmental andmulticausal agents. As long as popular culture’s view ofsickness and health is dominated by the pure biomed-ical approach, its understanding and confidence in thepublic health model will remain incomplete. In this re-spect, it becomes more difficult to believe that PPACAis a revolutionary document that represents irrevoca-ble cultural change or an absolute endorsement of thepublic health philosophy and approach.

Similarly, while public engagement in the PPACAdebate was unprecedented, attention focused largelyon the issues of access to medical care, insurance, andcosts—not on the substantial public health and pre-vention components of PPACA. As mentioned earlier,PPACA incorporated only some of the important in-sights of contemporary public health. For example,Judy Monroe, deputy director for Centers for DiseaseControl, recently ranked the factors that, the CDC be-lieves, most affect health. From smallest-impact-on-health-to-largest, these factors include counseling andeducation, clinical interventions, long-protective inter-ventions, changing the context to make individuals’ de-fault decisions healthy, and socioeconomic factors (thesocial determinants of health).41,42 Despite the identifi-cation of “socioeconomic factors” and “changing thecontext” as the most efficacious measures, PPACA pro-visions focus predominantly on the factors labeled ashaving the smallest impact, namely: clinical interven-tions, counseling and education, and protective inter-vention. It cannot be denied that the aforementionedprevention activities are important to the health ofindividuals, but coupling them with broader socialand environmental health determinant intervention isnecessary for maximal improvement in communityhealth status. Similarly, the Association of State andTerritorial Health Officials recently sponsored a con-ference titled “Making Health Reform More Than SickReform: Shifting the Focus to Better Population Health”in which attendees could expect to “Find out theways in which federal health reform will attempt toshift the current U.S. healthcare ‘non-system’ from itssole focus on medical care and insurance reimburse-ment, to a more rational system aimed at population-based health and wellness.” Despite the apparentpromise of conference theme, the titles of the con-ference presentations largely focus on preventive andpublic health remedies delivered in the medical caresetting.43

● Conclusion

In sum, when the US Congress passed PPACA in March2010, something important happened, although it is farless than a paradigm shift. To the extent that legislationin a republican political system is presumed to reflectin some way the public will, the inclusion of dozensof public health initiatives in PPACA and a relianceon public health philosophy in the legislation seem tosuggest that a change in society’s attitude may be un-derway. But dramatic legislative action is not alwayspredicated on an equally dramatic cultural transforma-tion. Legislators, after all, respond most readily to or-ganized interest groups and opinion leaders who helpshape the content of the legislation, rather than reflectdirectly broad-based cultural revolutions. Once innova-tive legislation is in place, cultural change may, or maynot, follow. For example, in pioneering civil rights leg-islation, in privacy protections, in safety and consumersafety measures, dramatic legislative and regulatory ac-tion preceded, instead of followed, the transformationin public attitude. Consciousness sometimes precedespolitical change, but political action sometimes inspiresconsciousness change. A similar dynamic may under-way here. Public discourse before and after passageof PPACA was predominantly focused on access andcost issues associated with the delivery of traditionalmedical care within the traditional physician–patientrelationship—a sign that public concern is not currentlyfocused on public health initiatives. Nevertheless, pub-lic health activists and groups were deeply engagedin the drafting of the health reform bill. According toJeffrey Levi,44 Director of Trust for America’s Health,a consortium of scores of public health groups “spokewith one voice” and were able to influence the finallegislative product in a way never before possible. Theresulting legislation represents both a symbolic victoryfor the public health approach and a very real oppor-tunity to advance the public health agenda if the im-plementation regulations and expropriations match theword and apparent intent of the PPACA provisions. Inaddition, the entitlement to such preventive care may intime transform the public’s understanding and respectfor such measures in a broader context.

But such change will require social conversion, andwill take time. PPACA may ultimately represent adefining moment, a crossing-over-the-Rubicon beyondwhich there will be no return to old modes of think-ing and behavior when it comes to health and healthpromotion. But that result is not foreordained. Whatindividuals think about health influences their incli-nations towards health services.45 Individuals consultphysicians because of their perceived susceptibility andvulnerability to illness.46 In contrast, the public does not




experience the immediacy of public health activities:“Turning on any kitchen faucet for a glass of drink-ing water without hesitation or peril is a silent homageto public health success, which would not have beenpossible at the start of the 20th century.”47 The keyterm here, of course, is silent homage. The spending ofstate and local public health agencies constitutes only2.4 percent of all US health care spending.48 Follow-ing 9/11 and the apparent looming threat of bioterror-ism, public health agencies had a new public healthprotection role. Many public health officials believedthat a new era with new resources was on the hori-zon. Although additional resources for public healthpreparedness were initially forthcoming from the Cen-ters for Disease Control and Prevention, sharp reduc-tions in the availability of these funds followed as soonas public attention waned. The transient nature of po-litical power in the United States and the vulnerabil-ities borne of difficult economic times will also be acontinuing challenge as we swim upstream. For now,as Koh and Sebelius6 suggest, a modest “Moving pre-vention toward the mainstream of health may wellbe one of the most lasting legacies of this landmarklegislation.”

REFERENCES

1. Patient Protection and Affordable Care Act, Pub. L. No. 111-148 (2010).

2. Silberman P, Lia CE, Ricketts TC. Understanding health re-form: a work in progress. N Carol Med J. 2010;71(3):215-231.

3. Obama’08. Barack Obama’s Plan for a Healthy America:Lowering health care costs and ensuring affordable, high-quality health care for all. http://www.barackobama.com/pdf/HealthPlanFull.pdf. Accessed October 6, 2010.

4. Benjamin GC. Health reform’s benefits arrive. The BaltimoreSun. September 22, 2010. http://articles.baltimoresun.com/2010-09-22/news/bs-ed-health-reform-20100922 1 health-care-health-reform-bill-health-spending. Accessed October6, 2010.

5. Jim McDermott. The Hill’s Congress Blog: Where LawmakersCome to Blog. August 23, 2010. http://thehill.com/blogs/congress-blog/healthcare/120507-health-care-reform-benefits-truth-vs-pure-politics-rep-jim-mcdermott. Ac-cessed October 6, 2010.

6. Koh HK, Sebelius KG. Promoting prevention through the Af-fordable Care Act. N Eng J Med. 2010;363(14):1296-1299.

7. Winslow CEA. The untilled fields of public health. Science.1920;51:23-33.

8. William ED, Redhead CS. Public Health, Workforce,Quality, and Related Provisions in the Patient Protec-tion and Affordable Care Act (P. L. 111-148). Congres-sional Research Service, June 7, 2010. http://www.ncsl.org/documents/health/PHwfQual.pdf. Accessed October 10,2010.

9. Engel J. Prevention in health reform: the time has come. NCMed J. 2010;71(3):259-262.

10. Healthcare.gov. http://www.healthcare.gov/center/regulations/prevention.html. Accessed October 10, 2010.

11. Pub. L. No. 111148, Sec. 2713.12. Pub. L. No. 111148, Sec. 4104-4108.13. Pub. L. No. 111148, Sec. 4103.14. Pub. L. No. 111148, Sec. 2705.15. Pub. L. No. 111148, Sec. 4207.16. Pub. L. No. 111148, Sec. 4205.17. Pub. L. No. 111148, Sec. 4002.18. Pub. L. No. 111148, Sec. 4001.19. Jacobson PD, Gostin LO. Restoring health to health reform.

JAMA. 2010;304(1):85-86.20. Beauchamp DE. Community: the neglected tradition of pub-

lic health. Hasting Cent Rep. 1985;15(6):28-36.21. Oberlander J. The politics of health reform: why do bad

things happen to good plans? Health Aff. 2003. Web exclusive.http://content.healthaffairs.org/cgi/content/full/hlthaff.w3.391v1/DC1. Accessed October 30, 2010.

22. National Institute for Highway Safety. Current US motor-cycle and bicycle helmet laws, 2010. http://www.iihs.org/laws/HelmetUseCurrent.aspx. Accessed October 30,2010.

23. Jones M, Bayer R. Paternalism and its discontents: motorcyclehelmet laws, libertarian values, and public health. Am J PublicHealth. 2007;97(2):208-217.

24. National Federation of Independent Businesses (NFIB).Letter in Support of the Johanns Amendment, 2010.http://www.nfib.com/issues-elections/issues-elections-item?cmsid=54565. Accessed October 30, 2010.

25. Raphael D, Bryant T. The state’s role in promoting popula-tion health: public health concerns in Canada, USA, UK, andSweden. Health Policy. 2006;78:39-55.

26. Pear R. G.O.P. to fight health law with purse strings. New YorkTimes. November 6, 2010.

27. Raphael D, Macdonald J, Labonte R, Colman R, HaywardK, Torgerson R. Researching income and income distributionas a determinant of health in Canada: gaps between theoreti-cal knowledge, research practice, and policy implementation,Health Policy. 2004;72:217–232.

28. Burstrom B, Diderichsen F, Ostlin P, Ostergren PO. Swe-den. In: Mackenbach J, Bakker M, eds. Reducing Inequalitiesin Health: A European Perspective. London, UK: Routledge;2002:274-283.

29. Stonington S, Holmes SM. Social medicine in the twenty firstcentury. PLoS Med. 2006;3(10):e445.

30. Welfare in Sweden: the balance sheet for the 1990s. http://www.sweden.gov.se/sb/d/207/a/885. Accessed Novem-ber 22, 2010.

31. McKee M, Jacobson B. Public health in Europe. The Lancet.2000;356:665-670.

32. UK Labour Party Manifesto. New labour becauseBritain deserves better. http://www.labour-party.org.uk/manifestos/1997/1997-labour-manifesto.shtml. Published1997. Accessed November 22, 2010.

33. Department of Health. Reducing Health Inequalities: An ActionReport. London, UK: Department of Health; 1999.

34. Department of Health, Saving Lives: Our Healthier Nation (Cm




4386). HM Stationery Office, London. http://www.archive.official-documents.co.uk/document/cm43/4386/4386-00.htm. Published 1999. Accessed November 22, 2010.

35. Novick LF, Mays GP. Public Health Administration: Principlesfor Population-Based Management. Gaithersburg, MD: AspenPublishers, Inc; 2001.

36. Olsen N. At last, a public health minister. BMJ. 1997;314:14981499.

37. Downgrading of public health post condemned as ‘setback.’http://www.hsj.co.uk/news/downgrading-of-public-health-post-condemned-as-setback/31225.article. Published1999. Accessed November 22, 2010.

38. Brandt AM, Gardner M. Antagonism and accommodationinterpreting the relationship between public health andmedicine in the United States during the 20th century. AmJ Public Health. 2000;90(5):707-715.

39. Starr P. The Social Transformation of American Medicine. NewYork, NY: Basic Books; 1983.

40. Starr P. Professionalization and Public Health: HistoricalLegacies, Continuing Dilemmas. J Public Health Manag Pract.2009;15(6): S26-S30.

41. Monroe J. Exploring the context: contemporary public health.Presented at: American Association of Medical Colleges;September 14, 2010; Cleveland, OH.

42. See also: Frieden TR. A framework for public healthaction: the health impact pyramid. Am J Public Health.2010;100(4):590-595.

43. Association of State and Territorial Health Officials. Na-tional Academy for State Health Policy. 23rd Annual HealthPolicy Conference, October 4-6, 2010. http://www.nashpconference.org/. Accessed September 28, 2010.

44. Jeffrey Levi interview with the author (LN) August 2010.45. Andersen R, Newman JF. Societal and individual determi-

nants of medical care utilization in the United States. MilbankQ. 2005;83(4):1-28.

46. Campbell SM, Roland MO. Why do people consult the doc-tor? Fam Pract. 1996;13(1):75-83.

47. Young QD. Public health: a powerful guide. J Health CareFinance. 1998;25(1):1-4.

48. Beitsch L, Brooks RG, Menachemi N, Libbey PM. Publichealth at center stage: new roles, old props. Health Aff.2006;25(4):911-922.


Swimming upstream _patient_protection_and.2

Health & Medicine

Transcript of Swimming upstream _patient_protection_and.2