What Has the United States Learned About the Role of Public Health as a Result of COVID?

Although funding and access to health care have long been important issues in American public policy, far less attention has been paid to issues relating to public health. Why the United States focuses so much more on medical care than it does on public health relative to other countries is a complicated question but, at least in part, it reflects the relative importance of market forces in the United States compared to other countries, as well as the focus on individual decision-making rather than reliance on governmental decision-making in matters of health care.

In the United States, the vast majority of health care spending goes to the delivery of personal health care services. In contrast, public health spending represented 3.7% of total health spending in 2000, but declined to 2.9% in 2018. Preventive health spending—a term used by the Organization for Economic Cooperation and Development (OECD), and close to what is included in public health spending in the United States—was a greater share of health care in the United States than in the Netherlands (2.2%), Japan (2.0%), and France (1.2%) but less than in Canada (5.9%), the United Kingdom (3.7%), and Germany (2.9%).

Unlike other countries, the amount spent for public health mostly occurs at the state and local levels rather than at the federal level. This differentiation may be at least as important, if not more important, than the absolute amounts of spending for prevention or public health. In 2018, prior to the pandemic, state and local governments spent $81.5 billion versus $12 billion spent by the federal government. The reliance on state and local governments for much of this financing means there are large geographic differences in spending for public health services. There is also concern about the accuracy of spending assessments for individual states because of differences in state accounting practices and reporting methods.

Learning from our experiences with the COVID-19 pandemic is important because viruses appear likely to be a part of our future. They may not all be as deadly or disruptive as COVID-19 (for example, the limited impact from SARS 2), but any new viruses are likely to require quick and appropriate responses.

In a paper written during the early part of the pandemic, I made a series of recommendations that remain relevant. These include having a pandemic expert as a member of the National Security Council and, thus, closer to the President than the Assistant Secretary for Preparedness and Response (ASPR) in the Department of Health and Human Services (DHHS). The ASPR remains important and responsible for: coordinating the HHS-wide response to a pandemic; quickly establishing which population or demographic group is most vulnerable to the virus; assuring that the country maintains prudent levels of stockpiled emergency equipment along with planned strategies for surge capacity; reviewing federal strategies for logical consistency; and making sustained efforts to involve the cooperation of the general public as well as the most affected populations to the extent possible.

The Commonwealth Fund Commission on a National Public Health System recently released recommendations for building a sustainable public health system. These recommendations were based on findings that public health efforts currently are not organized for success. They recommend that a single person or office at DHHS lead and coordinate the nation’s efforts, although it is likely that this already is the responsibility of the Assistant Secretary for Health (ASH). Since the ASH is separate from the ASPR, the current HHS structure may be contributing to the confusion.

Establishing how the Assistant Secretary for Health relates to the Assistant Secretary for Preparedness and Response as well as the authorities given to each is crucial. Establishing how both offices relate to the Centers for Disease Control and Prevention (CDC), which has a broad mandate to address strategies for detecting and responding to new health threats and to develop a public health workforce, is also critical.

The Biden Administration has responded to existing frustrations about who has the lead in a pandemic by designating the Office of the ASPR as a separate division charged with coordinating the country’s response to health emergencies. This change is expected to be phased in over two years and is hoped to lead to a quicker national response capability. Some public health experts have raised the concern that this designation loses the experience the CDC has had working with state and local health agencies.

The Commonwealth Fund recommended that a position such as an undersecretary for public health be established and that adequate and reliable public health infrastructure funding be provided.

Appointing a lead person in HHS, who would be senior to both assistant secretaries and to the director of the CDC before the next public health crisis occurs, would be very helpful even though the Secretary and President at the time could change the designation of a “point person.” This should be a task delegated to the Deputy Secretary, who functions as the chief operating officer of DHHS. Just as the placement of a health expert in the National Security Council and the relative power given to this person has varied over different administrations, it would not be surprising if the location of the office charged with combatting the next virus changed with different administrations. What is critical is that one individual, who heads an operating unit, needs to be designated as the lead person, and that other agencies that support public health efforts acknowledge the designated lead agency.

The national response to COVID-19 has created a great deal of confusion and frustration. Misunderstanding the nature and scale of the pandemic was not unique to the United States, but we can and must do better the next time the nation confronts a similar biologic and epidemiological challenge.

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