Module Components

• Overview
• Assignments

Topics

• Definitions
• Public Health Nursing Origins
• Basic Concepts
• Scope and Standards of Practice
• Public Health Nursing Roles

Nurs 467 - Public Health Nursing

Module 1: Foundational Concepts - Introduction

US Health Care System

The US public health system is comprised of a combination of agencies and organizations at all levels – federal, state and local. Care and services are mandated through laws developed each level. Read a brief introduction to public health infrastructure here.

FEDERAL

Overview

Federal authority for health care comes from the constitutional charge to provide for the general welfare of all Americans and from the federal role in regulation of interstate commerce. (Maurer & Smith, 2013). The federal government has the power to collect taxes and spend monies for the general welfare of the public. The executive and legislative branches of government make health policy decisions. Once policy is determined, the federal agencies are responsible for oversight and implementation.

The US Department of Health and Human Services (DHHS) bears the primary federal health–related responsibilities. The Centers for Disease Control and Prevention (CDC)and Health Resources and Services Administration (HRSA) are two of the DHHS member agencies that play major roles in the public health system infrastructure. The Assistant Secretary for Health (US Surgeon General) is responsible for the 12 agencies of the Office of Public Health and Science (OPHS)-, which houses the US Public Health Service Commissioned Corps the uniformed service of the US Department of Health and Human Services.

Federal Funding

The US health care system is financed by both private (direct pay, health insurance) and public funding sources. Medicare is the federal program for people over the age of 65 or who are disabled, while Medicaid covers low-income groups. Children’s Health Insurance Program (CHIP) -provides health care coverage for pregnant women and children who would otherwise not be eligible for Medicaid. CHIP and Medicaid are funded through state and federal matching funds. All three programs are administered through the Centers for Medicare and Medicaid Services. Other Department of Health and Human Services agencies, such as CDC, HRSA, and NIH, provide funding opportunities for specific State and Local health department and community programs through competitive grant funding cycles. They also extend “Requests for Proposals,” (RFP) for demonstration projects. Federally Qualified Health Centers (FQHCs) are an example of how the federal government funds community health clinics.

FQHCs are community-based organizations in underserved areas that provide comprehensive primary care and preventive care services to persons of all ages, regardless of their ability to pay or health insurance status. FQHCs are called Community/Migrant Health Centers (C/MHC), Community Health Centers (CHC), and 330 Funded Clinics. In return for treating patients regardless of ability to pay, “FQHCs receive consideration from the Federal government in the form of a cash grant, cost-based reimbursement for their Medicaid patients, and free malpractice coverage under the Federal Tort Claims Act.” (Centers for Medicaid Medicare Services, 2011).

FQHCs are a critical component of the health care safety net and are funded by the
Bureau of Primary Care. It is important to understand that even if health care organizations receive federal funding to assist with costs, like Planned Parenthood, these organizations do not necessarily qualify as FQHCs. To locate a Federally Qualified Health Center in Maryland go to: http://findahealthcenter.hrsa.gov/index.html

Some federal agencies, such as Veterans Affairs (VA) and the Department of Defense (DOD) provide direct care to specific populations. The VA provides direct health care to military veterans who have service-connected injuries, are 65 years or older, and /or are medically indigent. It is a source of care for those veterans who have exhausted other health care resources. The Department of Defense provides direct and indirect care to active military members and their dependents. The Department of Defense assumes responsibility for the health of all persons living on military bases and has a stake the community health of the military and their dependents.

The U.S. Department of Health and Human Services, through the National Health Service Corps, assigns health personnel to medically underserved areas.  The Indian Health Service (IHS) provides comprehensive health services through IHS and tribally contracted hospitals, health centers, school health centers, and other facilities to Native Americans and Alaskan natives.

State

Overview

Health departments constitute public health agencies on the state and local levels. The state health departments mirror the federal organizational structure in that they are comprised of separate public health units. Laws protect health, such as setting immunization requirements and monitoring the safety of the water supply. Federal, State and Local governmental agencies are often involved in the administration of a single program or basic service, such as Women, Infant and Children (WIC) Program or the State Children’s Health Insurance Program (CHIP).

The states derive their authority from the Constitution (Commerce Clause), which reserves for the states all power not specifically given to the federal government. States play a major role in directing and supervising the health activities of their citizens. The State health agency or health department is the principal agency for health care services in that state. The range of authority over health issues and the organizational structure of the state health department vary from state to state. The result is multiple organizational models and methods of service delivery by states.

The Association of State and Territorial Health Officers (ASTHO) is a working group comprised of chief health officials of the nation’s state and territorial public health agencies. Their mission is to formulate and influence sound public health policy, and to assist state health departments in the development and implementation of programs and policies to promote health and prevent disease. The service areas are linked to the three Core Functions and the 10 Essential Services of Public Health. If you’d like to learn more about ASTHO click here.

State agencies other than the health department also have health related responsibilities, these agencies include:

1. Departments of Education: health education policy
2. State board of Licensing
3. Vocational rehabilitation
4. Occupational Health
5. Health Planning
6. Environmental Health

State Funding

Flexibility exists at the state level to create policy and funding for Medicaid and SCHIP (MCHP in Maryland) waivers and demonstration projects. These actions enable states to cover additional citizens, provided the State uses the additional funding according to the federal requirements for matching funds.

The Maryland Medicaid program offers benefits to families and children, disabled persons or childless adults that meet eligibility criteria. In Maryland the Community Health Resource Commission  provides grant funding to health departments and safety net providers who seek to provide improved access to primary care services.

State Service Provision

While there may be state-level funded institutions, such as mental health facilities, the state health departments rarely operate primary care clinics. The state does provide many other services including health information, surveillance, and emergency preparedness. See the Maryland Department of Health for an example of state services. Click on the links and learn more about services offered by Maryland state agencies.

Local

Overview

Local Governments are created by the state government through delegation of authority to the local level. Each state legislature establishes roles and responsibilities of the local health departments, including their roles in the provision of health care. Various organizational structures exist and responsibility for health services, such as mental health and environmental health, may be under the purview of other government departments. The National Association of City and County Health Officials (NACCHO) has established itself as the “Voice of Local Public Health.” Its mission is to promote recognition of the critical work of local health departments in health promotion, disease prevention and protecting communities.

Click on the link to learn more about NACCHO National Association of City and County Health Officials. Scan The National Profile of Local Health Departments 2016 report for local health department information related to your state and jurisdictions of interest.

Local Funding

Local, state and federal governments share local health department funding costs. Federal Funding is available via grants for specific programs. The local, county or city government bears the majority of the financial burden for local health department operations. The state and local health systems subsidize the private system by insuring individuals who are unable to pay for services provided by these institutions.

Local Service Provision

Most of the responsibility for local health care rests with the local health departments. Many, but not all local health departments are involved in personal health care, such as Maternal and Child Health, Communicable Disease, and Immunization clinics. Some local health departments provide ambulatory health services for the poor.

Due to numbers of uninsured and the growing cost for their care, a network of Safety Net Providers has developed across the state. Some restrict their services to specific populations, such as county or community residents. These clinics usually provide primary care and case management services. Many of the health care centers hire an administrator and some hire providers, however most are staffed by volunteer physicians, nurse practitioners, and nurses.

Safety net clinic services are funded through a patchwork of funding streams. Often they are part of a public-private or community- public partnership. These clinics have the endorsement of the local health department, which may be involved in the partnership. Clients may be charged sliding fees based on ability to pay, contribute a donation or pay nothing.

If you would like to learn more about improving the health of underserved Baltimore City residents, review the services offered by Total Health Care.