Though responsibility for health care in the United States is, in unique fashion, both a public and private affair, in recent years, government—and most especially the federal government—has emerged as perhaps the single most important force shaping our health care system. This development has drawn attention to Washington and to what policymakers there are doing in health. Yet, as in other domestic policy areas, government’s role in health is shared. No level of government—federal, state, or local—has its own entirely autonomous sphere of action, and all three levels interact in shaping policy, in financing and delivering health care, and in running programs.The Washington DC Health Department Essay. Students of intergovernmental relations are familiar with Morton Grodzin’s now somewhat hackneyed metaphor for this state of affairs. The balance of government roles and responsibilities in America, he observed, looks much more like a marble cake than a layer cake with a clear separation of roles and functions. 1
However, despite the current preoccupation with events in Washington, increasingly we are seeing a rediscovery of the importance of the role of state and local governments in the health care field. Whether the issue is Medicaid, hazardous wastes, chemical spills, state rate setting or certificate-of-need, homeless persons on the streets of major cities, or lead paint poisoning, more and more attention is being focused on what state and local governments are doing in health. Several developments have spurred this apparent rediscovery of the state and local role, but three appear to be most noteworthy.
First, through his New Federalism initiatives, President Reagan has stimulated a fresh debate about the respective roles of each level of government in health as well as in other fields. This so-called New Federalism would substantially reshuffle the relationship between federal-state-local government, significantly expanding the role of the states in the governance and financing of domestic programs. President Reagan’s initiative has renewed awareness of important differences between liberals and conservatives on the respective roles of federal and state government— with liberals in recent years fearful of the motivations and capacities of state government, and conservatives equally fearful of any expansion of the federal purse or presence. The fate of the Medicaid program, among others, has been a hot issue in this larger debate.
Second, these are hard times for state and local governments. The tax revolt that began with Proposition 13, recent cutbacks in federal aid, and the nationwide economic recession have placed a severe burden on state and local governments. Their fiscal plight and their efforts to cope are receiving increasing attention, much of which has concentrated on the health area where state and local governments have been grappling with the problem of how to trim expenditures while still maintaining services and programs. The Washington DC Health Department Essay.
Third, and perhaps most important, in a period of belt-tightening and retrenchment at all levels, both the general public and professionals in the health care field are concerned that these cutbacks might threaten the nation’s health. Over the past twenty years, this country has made truly significant gains in access to health care and in health. For example, the poor in the U.S. now see a physician and receive hospital care at least as often as the nonpoor, and such health status measures as mortality and morbidity and infant mortality have shown steady improvement. 2 Though the evidence is not yet in one year or the other, there is now concern that the cutbacks that are being made threaten these gains. It is a concern that focuses not just on Washington, where broad financing and policy decisions are made, but at the state and local level as well, where the consequences of decisions are most visible and where services are actually delivered.
Thus, for philosophical, economic, and health care reasons, the role of state and local government in health is emerging both as an issue for professionals in the field and as a significant public issue as well.
The public officials who are the object of this attention face two broad challenges. The first is how to adapt, in the short term, to federal cutbacks and the pressures of today’s economy. In today’s economic climate, what choices and tradeoffs should state and local governments make in the health area? The second challenge involves the long-term role of state and local government in health. The fundamental question is whether state and local governments should refocus what they do in the health care field. Specifically, should more resources be invested in personal medical care or in public health, and what specific investments should be made in each area? Underlying these questions are historically difficult issues involving the role of the public and private sectors in health; the role of the different levels of government; and the adequacy of our knowledge base and the capacity of our political system for making tradeoff and priority decisions of this kind. The articles that follow address these challenges as well as these underlying concerns. As background, in this article we describe where things currently stand with regard to the state and local role in health. The Washington DC Health Department Essay.
THE EVOLUTION OF THE STATE AND LOCAL ROLE
Broadly speaking, the health-related activities of state and local government are: traditional public health, including health monitoring, sanitation, and disease control; the financing and delivery of personal health services including Medicaid, mental health, and direct delivery through public hospitals and health departments; environmental protection, including protection against man-made environmental and occupational hazards; and the regulation of the providers of medical care through certificate-of-need and state rate setting as well as licensing and other functions. Though we will not deal with these equally or comprehensively, a selective look at the history is useful in thinking about future roles and choices.
State and local government involvement in public health began with the great epidemics of the late eighteenth and early nineteenth centuries. The first of these, the yellow fever epidemic in Philadelphia, struck in 1793, and epidemics of cholera, small pox, and yellow fever were frequent occurrences over the next fifty years. 3 Initially, government responded to these epidemics by instituting quarantine measures and efforts to improve community sanitation. The Washington DC Health Department Essay. Generally these were directed by physicians appointed by the city or state government. Today we know that the causes of these epidemics were in large part social and economic. Counted among them were a rapidly growing and fast moving population; the urbanization of the Eastern seaboard which resulted in overcrowding, bad housing, inadequate sanitary facilities, polluted water supplies, and contaminated food; and the rapid expansion of the West, resulting in similar conditions on a smaller scale in new Western towns and communities. 4 However, the importance of these factors was not well understood in the early nineteenth century. Even when England and other countries were beginning to address these problems effectively, government in the United States was slow to respond. Due partly to the epidemics in Philadelphia, the nation’s capitol was moved from that city to Washington, D.C. in 1800.
At the local level in the early nineteenth century, a trend towards the full-time employment of persons to serve as the functional agents of local boards of health developed. This was the first step in the formation of local health departments. Health departments were established in Baltimore (1798), Charleston (1815), Philadelphia (1818), Providence (1832), and Cambridge (1846). 5 But many cities did not establish separate public health agencies for some time. For example, New York City appointed its first inspector of health in 1804, but from 1810 to 1838 inspectors of health operated as a branch of the police department, sharing responsibility for health matters on a day-to-day basis with a state-appointed health officer (who was concerned mainly with the application of quarantine laws to vessels entering port) and a resident physician, usually a municipal official whose function was to be on the alert for cases of communicable disease within the city. 6 In 1866, New York City formally established a central administration for health activities called the Metropolitan Board of Health. 7 Other major cities —Chicago (1867), Louisville (1870), Indianapolis (1872), and Boston (1873) —did likewise. 8
Even with these early beginnings, public health in this nation did not begin to evolve as we know it today until the latter half of the nineteenth century. The Washington DC Health Department Essay. During this period two major events took place. The first was the publication of the Shattuck Report by the Massachusetts Sanitary Commission in 1850. Though today heralded as the Magna Carta of public health, the Shattuck Report was not received with enthusiasm when it first appeared on the scene. The report was authored by Lemuel Shattuck of Boston, a bookseller and publisher who had become interested in public health through his activities in developing statewide registries for vital statistics. The Shattuck Report recommended the establishment of state health departments and of local boards of health in each town. In addition, it urged sanitary surveys of particular urban communities and other localities. 9 It was not until some nineteen years later, however, that Massachusetts established its first state board of health. California followed a year later, and by the end of the century, thirty-eight other states had followed suit.
The other significant development—really a series of related developments—involved breakthroughs in the study of bacteria and the diseases they produce. By the late 1800s, the discoveries of Pasteur and others had built a foundation of knowledge and technique for advances in the following decades that led ultimately to dramatic progress in the control of infectious diseases. Armed with this new science, health authorities began to act with greater discrimination in quarantine and environmental sanitation techniques. For example, knowing the incubation period of a given disease, they had a sound basis for setting the number of days required for quarantine. Knowing the conditions under which water or food transmitted disease, they could prescribe effective measures for control of such conditions. 10
This maturation continued into the early decades of the twentieth century. Beginning in the mid-1930s, it was substantially augmented by still another important scientific development, this one brought to the public through the personal medical care system rather than through public health per se. This was the “antimicrobial revolution” and the development and subsequent use of antibiotics in the delivery of personal health services. Even though there had been a decline in the frequency of certain infectious diseases before the full effects of these different breakthroughs were felt, the downward trends were increased dramatically as a result of them. The Washington DC Health Department Essay. Due in part to these advances, as well as improvements in living standards, nutrition, and other factors, trends in overall mortality rates showed dramatic decreases.
State and local health departments became the major vehicles by which these advances in both microbial science and environmental sanitation were made available to the public. As state and local health departments began to direct their attention to the causes of death and morbidity, they broadened and refined their activities. Services were made available to the community at large whether people were sick or not. Programs and activities were developed to aid those who were considered at the greatest risk of contracting disease. For example, the first children’s bureau in a city health department was established in 1908 because of a conscientious and inquiring child health inspector, Josephine Baker, M.D., who was appalled at the conditions in which pregnant mothers and their newborns lived. 11
As the nation moved into the 1900s, public health departments continued to refine their activities. In 1949, the Minnesota State Department of Health became the first to employ an epidemiologist; one year later it established a division of epidemiology. 12 In 1908 there were no county health departments; by 1920 there were 131. 13 Gradually, the traditional American ambivalence about government interference gave way to a desire for the benefits that government intervention could provide to the public through sanitation, control of communicable disease, and other traditional public health activities. The Washington DC Health Department Essay.
At the same time, state and local governments were playing an increasingly important role in the delivery of personal health services. Beginning as poor houses more concerned with welfare than providing medical services, the almshouses of the 1700s and 1800s evolved in the late 1800s into city hospitals whose primary purpose was to deliver medical services. In the early 1900s, these hospitals affiliated with medical schools and acquired full-time staffs. 14 Over roughly the same period, the inpatient population of state mental institutions grew to a peak of 560,000 in 1955. Now, as a result of the deinstitutionalization movement of the last twenty-five years, there are today less than 150,000 people in state mental hospitals. 15 How to care properly for those who have been discharged from state institutions or are no longer admitted to them is currently a difficult and pressing policy issue.
Today, the core of our “public” delivery system is the nation’s ninety urban public hospitals owned by city or county government and forty-five state-owned university hospitals. These 135 hospitals represent roughly two-thirds of the total public hospital beds in the United States. Most of the remaining 1,770 “public” hospitals serve as essentially community hospitals and admit predominantly private patients. They tend to be smaller and located in suburban or rural areas. Combined with selected voluntary hospitals with high Medicaid and free care caseloads— usually private teaching hospitals—these 135 institutions represent the country’s true back-up delivery system for the poor. 16 Though Medicaid and Medicare did enable large numbers of the poor to purchase care from private hospitals and physicians, the size and scope of state Medicaid programs varies tremendously, and the record across the country is uneven in this regard. As a result, despite the passage of Medicaid and Medicare, in many large cities these public and selected voluntary hospitals continue to play a vital role in delivering personal health services to the poor as well as to other special population groups, including alcohol and drug abusers, victims of violence, and the chronically mentally ill. Nationally, public hospitals in the nation’s 100 largest cities provide four times as much care for the poor, as a proportion of the total care they deliver, as do private hospitals in the same cities. (See Figure 1 .) On average, care for the poor—free care, bad debt, and care for Medicaid recipients—represents almost 40 percent of what public hospitals in the largest cities do. Today, ninety public general hospitals provide 13 percent of all inpatient services and 30 percent of all outpatient visits in the 100 largest cities. 17