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Feature: Public Health in the State Reform Spotlight

Recent state health reforms incorporate public health strategies to improve health outcomes and achieve a sustainable system of high-quality coverage. Access to care and coverage remain the centerpieces of reform, but recent experience—particularly in states that have undertaken significant coverage expansions, such as Massachusetts—make it clear that policymakers also must consider how to improve the quality of care and control costs. States such as Minnesota and Vermont that are struggling with budget crises and continually rising health care expenditures are realizing that, to control costs, they must reduce the incidence of disease, particularly chronic disease, and improve health outcomes. For these reasons, states are reemphasizing public health principles and applying them to health system reform.

Public health is what we, as a society, do to create the conditions in which people can be healthy—"the science and art of preventing disease, prolonging life, and promoting health and efficiency through organized community effort." 1Public health efforts are population-based, focused on prevention, and grounded in epidemiology, biostatistics, environmental science, management sciences, and behavioral and social sciences (Figure 1). States are adopting the public health viewpoint in reform to promote physical, mental, and social well-being and reduce the burden of illness among their residents.

This issue of States in Action examines the dynamics that are pushing public health into the state reform spotlight, including the unsustainable costs associated with potentially preventable chronic diseases, and the actions states are taking to integrate public health into their reform efforts. "States are again the innovators in health reform," says Paul Jarris, M.D., executive director of the Association of State and Territorial Health Officials. "They are creating new expectations for the system to not only treat sickness but also achieve health."

Figure 1. Ten Essential Public Health Services

1.       Monitor health status to identify and solve community health problems.

2.       Diagnose and investigate health problems and health hazards in the community.

3.       Inform, educate, and empower people about health issues.

4.       Mobilize community partnerships and action to identify and solve health problems.

5.       Develop policies and plans that support individual and community health efforts.

6.       Enforce laws and regulations that protect health and ensure safety.

7.       Link people to needed personal health services and assure the provision of health care when otherwise unavailable.

8.       Assure competent public and personal health care workforce.

9.       Evaluate effectiveness, accessibility, and quality of personal and population-based health services.

10.   Research for new insights and innovative solutions to health problems.

Source: Centers for Disease Control and Prevention National Public Health Performance Standards Program, 2009.

Preventable Diseases Fuel Health Spending
Much health spending is driven by early inattention to preventable diseases, which then become more expensive to treat as acute or chronic conditions. Treating patients with chronic diseases now accounts for 75 percent of the nation’s health care spending and 83 percent of state Medicaid spending.2 Two-thirds of the increase in health spending since 1987 is related to treating chronic diseases; the increased prevalence of obesity alone accounts for 20 to 30 percent of the rise in health care spending over this period.3

States are urgently seeking health reform strategies to "bend the curve" in health spending by addressing the underlying causes of chronic disease. According to the Centers for Disease Control and Prevention, motivating individuals to adopt five behaviors—maintaining proper weight, eliminating tobacco use, avoiding excessive alcohol consumption, increasing levels of physical activity, and adopting healthier eating habits—can help prevent and control cancer, heart disease, stroke, hypertension, diabetes, asthma, and pulmonary disease.4 State actions taken now to address risks to population health and provide timely and effective care are instrumental to improving health outcomes in the future.

Supporting Healthy Lives
The Commonwealth Fund State Scorecard on Health System Performance uses indicators of health outcomes such as rates of mortality amenable to health care and prevalence of smoking and obesity to measure how well states support their residents’ ability to lead healthy lives. The Scorecard reveals a wide range of health outcomes across the nation: for the most part, states in the Upper West and Upper Midwest tend to have better health outcomes, while the southern states fare the worst. There is also a pattern of worse health outcomes among some northern industrial states, including Michigan, Ohio, and Pennsylvania.5

The best overall indicator of variation in health outcomes among states is the rate of mortality amenable to health care. This measure includes age-standardized death rates before age 75 from conditions for which timely and effective medical care can potentially delay or prevent mortality. The Scorecard reveals wide variation in potentially preventable death rates among states (Figure 2). In the leading, lowest-rate states (Minnesota, Utah, Vermont, Wyoming, and Alaska), death rates were half those in the District of Columbia and the states at the bottom of the distribution (Tennessee, Arkansas, Louisiana, and Mississippi).

Improving health outcomes is a challenge for the health care and public health systems, as states grapple with factors such as rising obesity rates and high poverty rates that place individuals’ health and quality of life at risk. Heart disease, diabetes, asthma, and cancer rates are particularly high among low-income populations and in impoverished regions. As a result, states with high rates of poverty and income inequality tend to have high rates of mortality from conditions amenable to health care. The pathways through which individuals achieve optimal health are complex and each state faces unique challenges, but consistent measures of health outcomes provide useful targets for improvement.

Figure 2.

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 Avoiding Hospitalizations
The State Scorecard also indicates that efforts to strengthen preventive and primary care, and coordinate transitions between care settings, could improve population health and achieve savings through more efficient use of specialized and expensive resources. Public health activities such as vaccination drives and campaigns to educate people about chronic disease management have the potential to improve health outcomes and avoid unnecessary costs. For example, hospital admissions, readmissions, and emergency department visits may be averted through effective management of chronic conditions such as asthma and diabetes, and timely preventive care such as vaccinations against influenza and pneumonia. Some states, including Utah, Oregon, Washington, and Idaho, have notably low rates of potentially preventable hospital use (Figure 3). If all states could match the lowest rate of hospital admissions for conditions sensitive to ambulatory care and lowest rate of hospital readmissions, hospitalizations across the nation would be reduced by 30 to 47 percent and Medicare would save $2 billion to $5 billion each year.6 Potential savings would be still greater if similar reductions extended to all patients insured by private payers and Medicaid.

Figure 3.
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Connecting Public Health and Health Care
The importance of public health is not ideological or controversial—“prevention and wellness” are often the first words elected officials use when talking about health reform. But state officials must surmount challenges to incorporate public health principles into the day-to-day functioning of health care delivery systems. Public health and medicine share common roots but over time have grown apart: professionals in each field are trained separately and, for the most part, practice separately; state agencies separate authority for public health and health care; and the vast majority of health spending goes toward treating—rather than preventing——disease. In recent decades, traditional medicine has emphasized cures rather than prevention.

"For the longest time, it just didn’t occur to anyone—including public health leaders—to give public health a chair at the health reform table," says Paul Jarris of the Association of State and Territorial Health Officials. "Governors deserve a lot of credit for getting the public health viewpoint engaged in reform."

Recent health threats—anthrax in 2001, SARS in 2003, avian flu in 2004, Hurricane Katrina in 2005, and swine flu this year—boosted public awareness and governors’ understanding of the important role that public health initiatives play in health protection and promotion. After 9/11, new federal funding to support public health preparedness created opportunities for collaboration among public health agencies, law enforcement, and other health and human service agencies. These activities created new alliances that are now focused on health reform. Governors themselves have become more active—first out of necessity related to immediate health threats, and then by choice to promote healthy lives and address the looming threat of chronic disease.

Refocusing Traditional Public Health Activities
In the past, federal public health funding targeted at particular diseases led to multiple, overlapping state efforts focusing on similar prevention goals.7 Due to declining federal and state support, state public health programs are now combining disease prevention programs that target the same risk factors. Most states now have major initiatives under way to integrate public health and health care policies and systems to achieve improved health outcomes.8 For example:

  • Florida, Louisiana, Maine, and California have integrated multiple disease-specific programs by consolidating funding or administrative requirements.9
  • Hawaii, Illinois, Maryland, New Hampshire, New Mexico, North Carolina, and Virginia have established commissions or task forces to coordinate programs aimed at reversing trends in childhood obesity.10

Many states also are becoming more aggressive in how they promote health, often with the personal involvement of their governors. Arkansas led this trend when former Governor Mike Huckabee lost 100 pounds in 2004 and translated his experience into a mission to promote good nutrition. Other governor-led actions to promote health include:

  • Fifteen states support increased physical activity and healthy eating among children with funding from the National Governors Association's Healthy Kids, Healthy America initiative. The states are: Indiana, Kentucky, Louisiana, Michigan, Minnesota, Mississippi, New Mexico, New York, Rhode Island, South Dakota, Tennessee, Utah, Virginia, West Virginia, and Wisconsin.11
  • Sixteen states and the District of Columbia tax soft drinks or snack foods. The states are: Arkansas, California, Illinois, Indiana, Kentucky, Maine, Minnesota, New Jersey, New York, North Dakota, Rhode Island, Tennessee, Texas, Virginia, Washington, and West Virginia.
  • California (as well as New York City, San Francisco, Seattle, and Santa Clara County in Silicon Valley) now requires restaurants to publish calorie counts on menus and menu boards, and also (along with New York City, Boston, Philadelphia, and other cities) bans the use of trans fats in food preparation.

In addition, public health is central to many states' efforts to improve health information technology (HIT) infrastructure and accelerate electronic health information exchange (HIE). New York, for example, is funding a major initiative through the New York City Health Department to put electronic health records in small physician practices throughout the city (Figure 4). Public health agencies have operated electronic registries for decades, and states report that this experience will be foundational as they develop other HIT and electronic HIE activities. Twelve states rely on public health agencies to lead statewide HIT/HIE activities: Alaska, Florida, Georgia, Hawaii, Illinois, Maine, Michigan, Minnesota, Oklahoma, Rhode Island, South Dakota, and Utah.12

Figure 4. The New York Primary Care Information Project

The State of New York contributed $11 million to support a $68 million Primary Care Information Project (PCIP) led by the New York City Health Department to improve the quality of care in medically underserved areas through health information technology. The PCIP is the largest community electronic health record (EHR) project in the country, with 1,200 providers in small practices using EHRs as of May 2009. The goal is to have more than half of all high-volume Medicaid providers in New York City use a prevention-oriented EHR by May 2010.

The PCIP provides technical assistance to physicians to help them improve the health outcomes of patients, support for office redesign to improve office efficiency, coaching on EHR preventive-health features and how to use them for quality improvement, and a forum for discussing performance feedback and sharing best practices on quality improvement efforts. As much as possible, the PCIP intends to leverage the prevention-focused functionality built into the EHR to transform primary care practices into patient-centered medical homes (the specific goal is for practices to achieve Level II or III accreditation from NCQA, the National Committee for Quality Assurance).

Source: Amanda Parsons, PCIP Director of Medical Quality, presentation "Changing the Quality Paradigm" (May 14, 2009).


1. Institute of Medicine, 1988, and C.-E. A. Winslow, 1920,
2. Partnership for Solutions, "Chronic Conditions: Making the Case for Ongoing Care," Johns Hopkins University, September 2004.
3. K. Thorpe, "Two-Thirds of the Increase" in "The Rise in Health Care Spending and What to Do About It," Health Affairs, November/December 2005 24(6): 1436–45.; K. Thorpe, "Obesity Alone" in "The Impact of Obesity in Rising Medical Spending," Health Affairs Web Exclusive, October 20, 2004.
4. CDC, "Promising Practices in Disease Control and Prevention: A Public Health Framework for Action," 2003.
5. J. C. Cantor, C. Schoen, D. Belloff, S. K. H. How, and D. McCarthy, "Aiming Higher: Results from a State Scorecard on Health System Performance," Commonwealth Fund Commission on a High Performing Health System, June 2007.
6. Ibid.
7. CDC, "States Maximize Prevention Efforts," Healthy States newsletter published by the Council on State Governments, 2009. 
8. Twenty-six of 33 states that responded to this question. C. Hess et al., "States' Roles in Shaping High Performance Health Systems," National Academy for State Health Policy and the Commonwealth Fund, 2008. 
9. Robert Wood Johnson Foundation, "2008 Fall Balance Report," produced by the Albemarle State Policy Center, May 2009. 
10. Ibid.
11. NGA Center for Best Practices, "Healthy Kids, Healthy America." 
12. Florida and Illinois share the lead with another state agency; V. K. Smith, K. Gifford, S. Kramer et al., State E-Health Activities in 2007: Findings from a State Survey (New York: The Commonwealth Fund, February 2008).

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