U.S. Public Health 101 – Comprehensive Study Notes

Timeline of Key U.S. Health-Policy Events (Illustrated Wall Timeline)

1990-1991 – Creation/expansion of CMS programs.
1993 – Heated national debate on HMOs and managed-care frustrations.
1996 – (HIPAA era) incremental insurance reforms.
1997 – SCHIP established.
2001 – Early Medicare drug-benefit discussions.
2003 – President Bush signs Medicare Modernization Act;
(Part\ D \text{: prescription–drug benefit}); pledge “Drug Benefits a Kept Promise.”
2006 – Massachusetts enacts near-universal state coverage law (template for ACA).
2010 – President Barack Obama signs the Affordable Care Act (ACA):
- Sets minimum benefit standards, launches income-based subsidies, expands Medicaid, institutes individual mandate (penalty for non-coverage).
2012 – Supreme Court (5-4) upholds ACA mandate but makes Medicaid expansion optional.
2017 – Congressional attempts at “repeal & replace”; House passes bill, Senate fails; individual-mandate penalty later repealed via Tax Cuts and Jobs Act.

KFF “Health Policy 101” Resource Suite

Semester-style “mini-textbook” with self-contained chapters:
- Medicare 101, Medicaid 101, ACA 101, Employer-Sponsored Insurance 101, The Uninsured, Costs & Affordability, Private-Insurance Regulation, Women’s Health, Race & Inequality, LGBTQ+ Policy, U.S. Public Health 101 (current chapter), International Comparisons, Global Health, Public Opinion, Congressional/Executive Processes, 2024 Election Politics.
Authored/curated by Dr. Drew Altman (CEO, KFF); updated at least annually; feedback encouraged (daltman101@kff.org).

What Is Public Health?

Classic definition (Winslow 1920): “science and art of preventing disease, prolonging life & promoting health through organized societal effort.”
Institute of Medicine 1988: “fulfillment of society’s interest in assuring conditions in which people can be healthy.”
Turnock 2001: collective effort to address preventable, unacceptable realities.
DeSalvo 2017: “what we do together as a society to ensure conditions in which everyone can be healthy.”
Focus areas (non-exhaustive): communicable-disease control, chronic-disease prevention, nutrition, air & water quality, workplace safety, road-traffic injury reduction.
Distinguishing features vs. clinical medicine:
- Population vs. individual focus.
- Prevention & inequity-reduction over treatment.

Brief U.S. History Snapshot

1798 – Marine Hospital Service (first federal agency).
19th-century “Great Sanitary Awakening”: sanitation, hygiene, municipal boards.
1866 – New York City health department; 1869 – Massachusetts state board; subsequent proliferation.
1890s – Local/state infectious-disease labs; germ theory embraced.
1906 Food & Drug Act – first federal consumer-protection law (labeling & purity).
1922 Sheppard–Towner Act – first sustained federal funding to states (maternal/child health).
New Deal 1930s & Great Society 1960s – large federal expansion (CDC, Medicare, Medicaid).
1960s-present – cyclic “boom-bust” funding tied to threat perception & economics.
2020-2024 COVID-19 emergency – largest mobilization since 1918; temporary surge; subsequent retrenchment and political scrutiny.

Core Frameworks Guiding U.S. Public Health

Ten Essential Public Health Services (EPHS)

Assess & monitor population health.
Investigate & address hazards.
Communicate effectively.
Strengthen & mobilize communities/partnerships.
Create & implement policies/plans/laws.
Utilize legal/regulatory actions.
Assure equitable access to needed services.
Build/support diverse, skilled workforce.
Improve via evaluation & research.
Maintain strong organizational infrastructure.

Foundational Public Health Services (FPHS) Framework

Foundational Capabilities: assessment & surveillance; community-partnership development; equity; organizational competencies; policy development & support; accountability & performance management; emergency preparedness & response; communications.
Foundational Areas: communicable-disease control; chronic-disease & injury prevention; environmental PH; maternal/child/family health; access/linkage with clinical care.
Relationship: EPHS = ideal activity set; FPHS = minimum governmental package every jurisdiction should supply.

Defining Characteristics

Science-based decision-making; continuous updating.
Prevention orientation – benefits measured in “events that never happened.”
Health-equity lens – target underserved & vulnerable groups.

Social Determinants of Health (SDOH)

Five CDC/KFF domains: economic stability; education access & quality; health-care access & quality; neighborhood & built environment; social & community context.
Inequitable SDOH distribution creates disparities (e.g., food deserts → higher \text{BMI}, sick-leave scarcity → amplified epidemic spread).
PH departments urged to embed SDOH analysis across all 10 EPHS.

Governance & Legal Authority

Constitutional basis: 10th Amendment police powers (states); Commerce Clause & Spending Power (federal interstate control & funding); case-law precedent \bigl(\text{Jacobson v MA, 1905}\bigr).

Federal Level

Executive Branch

HHS umbrella – 13 divisions.
- CDC – lead PH agency; \$9.25\,\text{B} discretionary +\$8.03\,\text{B} mandatory (FY 24); director now Senate-confirmed (law 2022, effective 2025).
- FDA – regulates drugs, vaccines, devices, portions of food; FY 24 \$7.2\,\text{B} program level (46% user fees).
- ASPR – preparedness & response (BARDA, Strategic National Stockpile); FY 24 \$3.65\,\text{B}.
- HRSA, SAMHSA, NIH etc. deliver ancillary PH functions.
Non-HHS federal actors:
- USDA (SNAP, school nutrition, FSIS).
- EPA (environmental standards, drinking water).
- DoD (service-member health surveillance), DHS (preparedness grants), OSHA (workplace health), VA (veterans’ public health).

Legislative Branch (Congress)

Passes statutes, appropriates funds (vast majority discretionary), conducts oversight.
Can pass emergency supplementals (e.g., >\$60\,\text{B} for COVID-19 across 6 bills).
Split jurisdiction: Energy & Commerce, HELP, Appropriations, etc.

Judicial Branch

Reviews legality of PH actions (e.g., mask mandates, vaccine rules, quarantine authority).
Precedents evolve; pandemic spurred fresh litigation (CDC transit mask rule voided April 2022).

State, Territorial, Local & Tribal

50 states, DC, 5 territories, 3 Freely Associated States each run own health department.
Governance typology (ASTHO 2022): 16 centralized, 27 decentralized, 8 mixed/shared.
Local layer: \approx3{,}300 county/city health departments + 574 tribal governments.
Common state activities (2022 ASTHO):
- 100% – communicable-disease control, surveillance, immunization logistics, public-health labs.
- High prevalence – chronic-disease prevention, WIC, tobacco control, cancer screening, food-safety inspections.

Non-Governmental & Academic Actors

Associations (ASTHO, NACCHO, CSTE, AIM, APHA, TFAH) = advocacy & technical hubs.
Philanthropy & community-based orgs = funding, program delivery.
Academia: 66 schools + 164 graduate programs + 29 undergrad programs.
Private sector (pharma, diagnostics, IT, media) integral to surveillance, countermeasures & communication.

Public Health Funding Landscape

Mixed sources create “boom–bust” cycles.

National Expenditure Snapshot (CMS NHEA-PHE line)

\text{Range 2013–2023}:\ \$80\,\text{B}\rightarrow \$240\,\text{B}.
2023: \$160\,\text{B} = 3.3\% of total \$4.87\,\text{T} health spending.

CDC Grants to Jurisdictions (FY 23)

\$15\,\text{B} total; top per-capita recipients – DC, Alaska, Maryland, Vermont.

State Budgets (ASTHO FY 21)

Funding mix: 53\% federal, 36\% state, 11\% other.
Largest spending categories 2021: COVID-19 response, clinical care, WIC.

Local Budgets (NACCHO 2021)

Source mix: 55\% federal (26 pass-through + 25 direct + 4 Medicaid/Medicare), 21\% state, 14\% local, 10\% other.
Mean local per-capita outlay \$78 (median \$49).

Estimated Funding Gap

Needed FPHS baseline ≈ \$32 per capita; pre-COVID (2019) actual ≈ \$19 → gap \$13/person/year.

Public Health Workforce

Duties span clinical services, epidemiology, inspections, program management, communication.
2009–2019: Local-dept workforce fell 17\% (162k → 136k).
Pandemic surge: NACCHO counts 182\,000 LHD staff in 2022 (record high); CSTE counts 5{,}706 state/territorial epidemiologists in 2024 (↑38% since 2021).
Challenges: uneven rural distribution, burnout, low pay, impending contract & grant expirations as COVID funds sunset.

Communication in an Era of Declining Trust

Health communication = one of 10 EPHS & FPHS capabilities.
Success stories: tobacco, seatbelts, nutrition activity.
Current obstacles:
- Fragmented messenger ecosystem → info overload.
- Rapidly shifting media & social networks.
- Documented trust erosion, especially among Republicans (KFF polls).
- Politicization post-COVID.
- Misinformation vs. disinformation.
Mitigation tactics:
- Coordinate messages; partner with social-platforms.
- Diversify & tailor channels; emphasize trusted local voices.
- Two-way engagement (“malleable middle”).
- Rapid correction with evidence.
- Continuous evaluation & sustained community presence.

Current Topical Issues

Disease Surveillance & Reportability

Surveillance = continuous collection ➜ analysis ➜ interpretation.
State laws define “reportable” conditions (mandatory provider/lab report, often with identifiers).
CDC’s NNDSS receives de-identified voluntary data; maintains annually revised “notifiable” list (123 conditions – 2023).

Federal Emergency Declarations: Who Can Invoke What?

President – National Emergency (NEA §201); renew yearly; unlocks Medicaid/Medicare flexibilities.
HHS Secretary:
- Public Health Emergency (PHS §319): 90-day window, tap emergency funds, waive program regs, fast grants/contracts.
- EUA declaration (FD&C §564): enable emergency authorization of vaccines/tests/drugs.
- PREP Act §319F-3: liability immunity for countermeasure developers & administrators.
Scope limits: states retain primary police powers; federal mandates confined to interstate travel, federal workforce, immigration, etc. Litigation has constrained CDC authority (e.g., Title 42 migration; transport masks).

Water Fluoridation Debate

CDC lists fluoridation among “Ten Great PH Achievements 20th C.”
Authority tier:
- EPA sets maximum contaminant levels.
- States/localities decide whether to fluoridate; some mandate for systems ≥ certain size; others via municipal referendum.
Political headwinds: Secretary RFK Jr. signals intent to recommend removal; professional bodies still endorse.

Future Outlook & Political Context (2025-?)

Decentralized “patchwork” yields tailored solutions but hampers national coordination; capacity inequities persist.
Post-COVID politicization + budget squeeze jeopardize recent gains.
New Trump Administration actions (early 2025):
- Proposes deep cuts at HHS, CDC, FDA, NIH; rolls back DEI & LGBTQ+ initiatives.
- Secretary Kennedy signals shift toward chronic-disease focus, vaccine-safety skepticism, deprioritizing infectious-disease programs amid measles & H5N1 threats.
- “Nothing off limits” approach foretells regulatory upheaval.

Selected Resources for Further Study

KFF Health Information & Trust Program; trend briefs on public-trust decline.
KFF explainer series on HHS, FDA, CDC influence over vaccine policy.
Institute of Medicine reports: “Future of Public Health” (1988), “Public Health 3.0” (2017).
TFAH, ASTHO, NACCHO websites for real-time workforce & funding dashboards.
Wallace & Sharfstein, “The Patchwork U.S. Public Health System,” NEJM.