Is it time for a national public health system?

To better understand the rationale, I spoke with three commission members. Former New York state health commissioner Nirav R. Shah explained to me that there is a fundamental problem with public health in America that long predated the pandemic: “It’s disorganized, under-resourced, poorly coordinated and disconnected from the health-care delivery system.”

He’s right. There are nearly 3,000 local health departments with vastly different capabilities. Depending on where someone lives, they could be served by a well-funded city or county health agency that provides many safety-net services, or one with a handful of staff and a shoestring budget. The result is evident in the disparities seen during the pandemic: Some areas were quick to set up big vaccine clinics and free testing sites; others struggled with the basics of contact tracing.

The Commonwealth Fund commission wants to set a national standard for health department capabilities and help them achieve it through new funding. The latter part, to me, is the most important part of their proposal: a federal government commitment to sustained and reliable funding for local public health.

When I served as Baltimore’s health commissioner, my biggest challenge was lack of staff. The same people who worked on the opioid epidemic and maternal and child health were called on to respond to weather emergencies and disease outbreaks. Every crisis was like robbing Peter to pay Paul, with each new problem diverting attention away from existing priorities.

Over the past decade, state and local health departments have lost 15 percent of their essential staff due primarily to budget cuts. A one-time grant, such as Congress’s American Rescue Plan, is not a long-term solution. “Millions of dollars of pandemic funds are unspent because they come with a fiscal cliff,” Shah explained. “If you hire people this year, what happens to them next year?”

That’s why the commission is seeking approximately $8 billion from Congress every year, with the bulk of it addressing local workforce shortages. The rest will pay for a revamped data system that connects public health agencies and hospitals. Julie Gerberding, another commission member, told me that this could have made a big difference during the early days of covid-19.

“If we had real-time information exchange, we might have detected hotspots much earlier,” she said. “We might have noticed outbreaks at meatpacking plants, and that the average age of intensive care admissions was going up; we might have focused efforts sooner at workplaces and nursing homes.”

Commission members are quick to point out what a national public health system is not. Gerberding, who served as director of the Centers for Disease Control and Prevention during the George W. Bush administration, is clear that the proposal isn’t to federalize public health, but to set standards. “Our goal is to make sure that there are basic public health protections for everyone regardless of where they live.” She is careful to say even as there needs to be better national coordination, local and state control is paramount.

I think this distinction is really important. Local health departments should be better funded so that they can respond to emerging crises without having to pull their staff from other day-to-day duties. Federal agencies can also be better coordinated among themselves (another issue that the report addresses).

But public health in the United States won’t work with top-down control. City and county health officials know their communities best and must be empowered to make local decisions. There is also a real danger in giving the federal government too much power. Just think about what could happen if a president who, for example, promotes anti-vaccine conspiracy theories has greater control over public health policies.

Is the Commonwealth Fund proposal realistic? If Congress can’t get its act together to allocate $10 billion for boosters and antiviral pills, what are the chances that it will agree to a new annual line item? The chair of the commission, Margaret Hamburg, who served as the health commissioner of New York City and then head of the Food and Drug Administration, is undeterred. “Trillions of dollars have been lost because of the pandemic,” she told me. “The amount we’re asking for is such a small amount compared to what the absence of a coordinated public health response has cost us.”

Put another way, the United States can’t afford not to reform its underfunded and outdated public health system. I hope policymakers will read this report and use it as a blueprint for taking concrete, practical actions to safeguard our nation’s health.