Executive Summary
More than 1 million Americans have died from COVID-19, a toll that exceeds the total number of U.S. combat deaths from all wars since the nation’s founding. The United States is also failing to protect millions of people from growing health challenges, such as overdoses, diabetes, and maternal mortality. The scale of these challenges justifies the development of a national public health system to save lives every day and better prepare for future emergencies. The Commonwealth Fund Commission on a National Public Health System finds that:
- Public health efforts are not organized for success. Despite dozens of federal health agencies and nearly 3,000 state, local, tribal, and territorial health departments, there is no single person or office at the U.S. Department of Health and Human Services to lead and coordinate the nation’s public health efforts.
- Public health funding is not sufficient or reliable. The chronic underfunding of public health has left behind a weak infrastructure, with antiquated data systems, an overworked and stressed workforce, laboratories in disrepair, and other major gaps.
- Expectations for health agencies are minimal. Funding is not tied to a set of basic standards for the capabilities of state, local, tribal, and territorial health departments.
- The health care system is missing opportunities to support health improvement. It is difficult to convert collaboration with public health agencies during emergencies into sustainable work to address day-today health challenges.
- The public health enterprise is facing a crisis in trust. This crisis relates to experiences with racism and discrimination, ideological opposition, and misinformation.
The United States should build a national public health system to promote and protect the health of every person, regardless of who they are and where they live; implement effective strategies with others in the public and private sectors; respond to both day-to-day health priorities and crises with vigor and competence; and, in the process, earn high levels of trust. In this report, the Commission provides a detailed set of recommendations to achieve this vision, which include the following:
Congress should:
- Establish a position, such as an undersecretary for public health at the U.S. Department of Health and Human Services (HHS), to oversee and coordinate the development of the national public health system.
- Provide adequate and reliable public health infrastructure funding, paired with expectations that states, localities, tribes, and territories meet standards for protecting their communities.
- Fund a modern public health information technology system and provide HHS with the authority to make it work.
The Administration should:
- Set parameters for use of available funds to systematically build public health infrastructure, with an initial focus on workforce and data systems.
- Support revision of accreditation standards for state, local, tribal, and territorial health departments to focus on basic capabilities for public health protection.
- Establish a council to coordinate federal public health action with states, localities, tribes, and territories.
- Reconvene the National Prevention and Public Health Council to guide an all-of-government approach to the drivers of health.
- Embrace ethics, integrity, and transparency in decision-making in public health.
States, localities, tribes, and territories should:
- Assess the structural and policy changes needed to provide foundational capabilities for all their residents.
- Build connections between the health care system and public health to strengthen day-to-day health improvement efforts and better prepare for emergencies.
- Involve community partners in decision-making about public health.
Modernizing public health in the United States is not a simple task, but it cannot be ignored. The window for change is open, and the moment of opportunity is now.
