Leading the World Again: Creating a 21st-Century Public Health Agency

America’s failure to adequately respond to COVID-19 was abetted by political obstruction coupled with failures of science and public health response practices and a chronically underfinanced public health system.^1–4 A robust public health system is critical to the prevention of catastrophic public health failures, health promotion, and elimination of health inequities. A roadmap for public health reform to prevent the next pandemic requires modern data infrastructure; improved federal, state, and local partnered governance; and proper financing.

DATA INFRASTRUCTURE

It is no longer tenable that Google knows more about the health of an individual or, collectively, a community than our public health system. Disease monitoring is a support function at the Centers for Disease Control and Prevention (CDC), currently with more than 100 stand-alone proprietary systems scattered across the agency and into 3000 state, tribal, local, and territorial jurisdictions. The CDC lacks a biosurveillance system that can collect, analyze, and share data in real time for public health action. The agency has admitted that if it had such a modern data infrastructure, it would have more quickly and effectively contained the spread of the coronavirus.^5,6

The United States should expand traditional surveillance activities and strive to permit access to the right information to influence action by the right person at the right level at the right time. These data could be federated with multiple layers of identity management, service-level agreements, and contractual definitions to maintain security and privacy protections. Individual-level geocoded data from case-based surveillance tied to a national patient identifier⁷ could be used to expand event-based and community-based surveillance. This identifier would be linked to health care utilization data including nontraditional data sources such as social media, commercial databases, and individual and community data on social determinants of health. These data need to be coupled with modern analytic techniques such as computational intelligence and automated rule-based expert systems to derive information that can rapidly trigger notification of new health threats.

If such a system had existed, the CDC and the nation would not have been surprised by the opioid epidemic or the COVID-19 pandemic. These data could be used in a proactive manner to create a better understanding of the financial benefits of improving health, which could encourage longer term investments in or solicitation of health impact bonds.

Public health surveillance is the core of public health, and the CDC should lead surveillance efforts. The National Center for Health Statistics should have data sets populated with health care and cost data from agencies such as the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, and the Office of the Assistant Secretary for Preparedness and Response. This system would rapidly move hospital data to the forefront as needed and be the data source driving and monitoring public health programmatic activities.

Organizationally, the CDC would create a position of chief health data scientist. This individual, in partnership with representatives from other agencies, could help to create a holistic picture of people and communities. The CDC should lead efforts to bring together diverse data sets from social services, workforce agencies, and public safety to help build a comprehensive picture of both medical and social vulnerabilities and help align social services and sources of medical support to achieve optimum and equitable health. With these comprehensive data, communities, health systems, and public health officials at the state, tribal, local, and territorial levels will have a holistic view of the drivers of poor health and be better equipped to address them.

STATE, TRIBAL, LOCAL, AND FEDERAL PARTNERSHIPS

Recent national failures in public health were not only mirrored but magnified at the state, tribal, local, and territorial levels. Most state, tribal, local, and territorial health departments are underequipped to properly respond to public health emergencies. A set of essential functions, capabilities, and capacities at all levels of public health must be codified and properly resourced for the future.

The administrative burden on states (and the CDC) could be eased by eliminating separate fiefdoms within each congressional program while maintaining accountability for impact and streamlining emergency authorities for grants. Additional and unique CDC health officers should be assigned as advisors to each state and large tribal, local, and territorial health departments. These health officers would be charged with facilitating federal assistance and would help guide the use of federal funds to enhance health protection, prevention, and promotion efforts across jurisdictions. Health protection should concentrate not only on mitigation of threats from novel pathogens but also on provision of safe water, food, and air; healthy building codes; and workplace safety.

Cross training of scientists and mandatory rotations, scientific reviews, and external reviews should be implemented to modernize the public health workforce. Existing public health staff can be augmented by revitalizing the Commissioned Corps of the Public Health Service, expanding the Epidemic Intelligence Service, and resourcing other fellowships in public health, informatics, and data and laboratory sciences. Groups such as a noncommissioned public health corps of community health workers and a ready reserve corps could be established for rapid scale-up during an emergency.

A new formal public health governance model analogous to the Federal Communications Commission should be created. This national public health commission should be an independent government agency overseen by Congress and chaired by the CDC, populated with individuals appointed by the secretary of health and human services, and including members from states and localities that serve across administrations. This commission would create and fund America’s national protection, prevention, and health promotion strategy. The commission would support activities that cut across national, state, and local levels; ensure accountability of state, tribal, local, and territorial entities and intrastate coordination; and review proposed spending from the new public health trust fund proposed in the next section.

FINANCING MODEL

The United States spends $3.5 trillion annually on health care but less than 3% of that total on public health, as compared with 10% spent on public health by many other wealthy countries.⁸ A possible model to adequately fund public health would be a check-off or tax on all health care spending, including a surcharge on private insurance and an appropriation of a portion of Medicaid and Medicare funds to the CDC.⁹ This new trust fund would replace the current Prevention and Public Health Fund and fund national priorities outlined in the national protection, prevention, and health promotion strategy and the Healthy People 2030 plan.

In addition, nonprofit hospitals need to be more accountable for community benefit dollars they “spend” to maintain their nonprofit status. Community benefit dollars should have measurable and tangible linkages to community needs and be spent in alignment with local priorities currently identified by community health assessments, with a defined minimum floor of dollars that need to be spent on community benefit to qualify for tax-exempt status and much clearer guidelines on how these dollars should be allocated.

CONCLUSIONS

A well-funded and strong public health infrastructure, with actionable data and robust partnerships, is essential to strengthening our country’s physical and fiscal health. We must restore public trust and reengineer the role of public health as central to a well-functioning health care system and essential to achieving optimum health. If properly funded and staffed and armed with proper data, solid partnerships, and the best technologies available, public health agencies can effectively protect against future health threats and build a foundation for achieving the optimal and equitable health of every person in our nation.