Governmental public health agencies have long played extensive roles in delivering personal health services to people who lack access to mainstream medical providers. And for just as long, these roles have generated policy controversy because of their potential to dominate agency budgets and attention, crowding out the ability to support activities with larger, population-wide health impact. A new paper by UCLA’s Charleen Hsuan and Hector Rodriguez offers some important insight into these dynamics and their implications for population health. But first, let’s recap a few of the basic issues in play.
Some of the best insight into the origins of this controversy and its longer-term dynamics comes from Princeton’s Paul Starr and his revealing sociological analysis ( book and paper) of how public health has evolved over time in tandem and in conflict with the U.S. medical profession. In recent years, many public health agencies have scaled back the delivery of personal health services, and such delivery is expected to decline even further as health insurance coverage expands with the Affordable Care Act (ACA) implementation.
Public health’s movement away from direct provision of personal health services has some serious possible advantages, but probably only under certain circumstances. If agencies that discontinue these services are able to retain some of the resources that formerly supported clinical care and reinvest them in the delivery of effective disease prevention and health protection programs and policies, then real gains in population health are possible. This type of reinvestment – which was recommended in a recent report from the Institute of Medicine on public health financing – is likely to be possible for many agencies that currently must use some of their discretionary funding from state and local appropriations to fill the gaps between clinical revenues and clinical expenditures. As many safety-net providers know, the delivery of clinical services to low-income and underserved populations is often far from self-financing.
At the same time, there are some serious potential downsides to reducing the joint production of public health and personal health services. Synergies in the production and consumption of the two types of services seem quite plausible, although solid empirical evidence of such is generally lacking. Disease and injury risks tend to cluster in the low-income populations who most often receive personal health services from public health agencies, so the opportunity exists to layer on the delivery of prevention programs like tobacco prevention and cessation, nutrition education, physical activity promotion, and injury and violence screening and prevention interventions when people seek care from public health agencies. However, most public health agencies offer only selected personal health services (e.g. immunizations, sexually transmitted disease testing and treatment, maternal and child health support services) rather than comprehensive primary care medical services to their clients, creating natural limits to the possible synergies. In theory, even greater synergies in production and consumption would be possible if full-service primary care providers were to take up the task of jointly producing these types of prevention programs, using models like the medical home, the medical community and the accountable care organization. Such synergies could also be realized through models that closely coordinate and integrate the services delivered by public health and primary care providers (models that yield what Nobel economics prize winner Elinor Ostrom termed coproduction synergies). But if public health agencies scale back the joint production while medical providers fail to take up joint production in equal measure, then a net loss in synergy could result, causing overall reductions in the reach, effectiveness and efficiency of prevention programs.
Adverse effects are of particular concern in communities where an adequate supply of medical providers is not available or not willing to serve the underserved. Of particular concern are the millions of U.S. residents who will not gain insurance coverage under ACA because they reside in a state that has chosen not to expand Medicaid, because they lack residency status in the U.S., or because coverage otherwise remains unaffordable. Scaling back personal health services can also be problematic for public health agencies that rely on earnings from clinical reimbursements to cross-subsidize other high-value public health activities such as population-based disease prevention and injury prevention programs. Again, empirical evidence for this type of cross-subsidization is scarce, but it remains a possibility for agencies that succeed in making selected clinical services self-financing.
The new paper by UCLA’s Charleen Hsuan and Hector Rodriguez examines changes in the delivery of personal health services by local health departments between 1997 and 2006, taking a careful look at the characteristics of agencies and communities that either scale back or ramp up their joint production during this period. Using data from our own National Longitudinal Survey of Public Health Systems, the analysis offers some reassuring evidence that local agencies are able to make context-specific decisions about joint production in ways that mitigate adverse effects on service delivery. While most agencies reduced the delivery of clinical services during this time period, a sizable minority (22%) maintained or increased these services. Those that discontinued services tended to do so in communities that experienced growth in the availability of other providers of services to underserved populations. Agencies that increased clinical services delivery tended to do so primarily for Medicaid-reimbursable services that offered revenue and cross-subsidy possibilities.
These results offer encouraging news about the ability of public health agencies to balance public health and personal health services needs during ACA implementation. Because these results are based exclusively on pre-ACA data, it will be important to continue monitoring the trends in joint production and their health and economic consequences. This study was supported through the Robert Wood Johnson Foundation’s program in Public Health Services and Systems Research. Our research center has ongoing and forthcoming studies on this topic, and new waves of data from the National Longitudinal Survey, so stay tuned to this blog for further discussions of emerging findings.
Public Health Economics 
Thanks, Glen, for sharing the results of this recent study. You observe the adaptability of local health deparments to circumstances found within their own communities as well as the importance of local health department clinical services in many areas of the U.S. The variability of local circumstances helps explain some of the variability in the types of services local health departments provide (or seek to provide).
The study period also preceded The Great Recession during which time many local health departments saw reductions in discretionary local resources as well as reductions in state general support (where it existed) and federal categorical resources. ACA-generated stimuli waxed and waned, too. As a result it will be interesting to see whether departments continue(d) the delivery and subsidy of clinical services (whether these were categorical or not) or shifted amounts remaining into population health-based activities (or neither!). We are moving through a period of disassembly and, hopefully, reassembly.
Some states with centralized models of organization have also directed their local health departments to move away from, or into, the delivery of clinical services in the past few years. Hence the decision to provide clinical services may not be a local one.
It would be interesting to learn the source of revenue for those 22% of departments which increased the delivery of clinical services and whether those departments participated as HRSA community health centers or look-alikes or “simply” generated clinical revenue through better managed or newly created billing systems.
Local health departments are faced with the challenge of “knowing” and “serving” in ways that are the same and different from their state and federal governmental public health colleagues. It’s a challenging aspect of their work and, unlike some of their other local govermental organizational colleagues, particularly in the human services or clinical sector, has no state or federal “patron” to support the range of their work or to see them as the preferred practitioner. It’s another one of the great divides in public health practice.
Bobby makes excellent points here that begin to map out an agenda for future research on this important topic. Clearly there are critical health and economic implications that lie in the balance. And with newly available data on service delivery from NACCHO’s 2013 National Profile of Local Health Departments survey, now is the time to pursue these lines of inquiry.