Question

Describe the levels of government and their roles in the health promotion for U.S. populations. How does the state health department provide links between federal and local health agencies?

Answer 1

• Role of State and Local Governments in Assuring Population Health

States and their local subdivisions retain the primary responsibility for health under the U.S. Constitution. To fulfill this role, state and local public health authorities engage in various type of activities, including monitoring the burden of injury and disease in the population through surveillance systems; identifying individuals and groups that have conditions of public health importance with testing, reporting, and partner notification; providing a broad array of prevention services such as counseling and education; and helping assure access to high-quality health care services for poor and vulnerable populations. State and local governments also engage in a broad array of regulatory activities. They seek to assure that businesses conduct themselves in ways that are safe and sanitary (through the institution of measures such as inspections, licenses, and nuisance abatements) and that individuals do not engage in unduly risky behavior or pose a danger to others (through the provision of services such as vaccinations, directly observed therapy, and isolation), and they oversee the quality of health care provided in the public and private sectors.

• Role of Tribal Governments in Assuring Population Health

Although their legal status varies, tribal governments have unique sovereignty and right to self-determination that is often centered on treaties with the federal government. Under these given treaties, the federal government has an obligation to provide tribes with certain types of services, including health-related services. In addition, American Indians and Alaska Natives are eligible as individual citizens to take part in state health programs. However, in some situations, tribal-state relations are strained, and there are often misunderstandings about the relative responsibilities of states and tribes for the financing of health care and population-based public health services. Until the mid-1970s, the federal government directly provided health care services to American Indians living on reservations and to Alaska Natives living in villages through the Indian Health Service (IHS), an agency within DHHS. In 1975, the Indian Self-Determination and Education Assistance Act established two other options for obtaining these services: (1) tribal governments can contract with IHS to provide the services or (2) administrative control, operation, and funding for the services can be transferred to a tribal government. In the mid-1970s, the legislation also authorized funding health services for American Indians living in urban areas. The operation of IHS programs depends on annual discretionary appropriations, which are generally considered inadequate. Some tribes are able to supplement IHS funding, but many cannot. Many tribes have health directors and operate extensive public health programs that include environmental safety and community health education, as well as direct curative and preventive services.

• Role of the Federal Government in Assuring Population Health

The federal government acts in six main areas related to population health: (1) policymaking, (2) financing, (3) public health protection, (4) collecting and disseminating information about U.S. health and health care delivery systems, (5) capacity building for population health, and (6) direct management of services . For most of its history, the U.S. Supreme Court has granted the federal government broad powers under the Constitution to protect the public's health and safety. Under the power to “regulate Commerce . . . among several states” and other constitutional powers, the federal government acts in areas such as environmental protection, occupational health and safety, and food and drug purity. The federal government may set conditions on the expenditure of federal funds (e.g., require the adoption of a minimum age of 21 for legal consumption of alcoholic beverages to receive Federal-Aid Highway Funds), tax commodities whose use results in risky behavior (e.g., cigarettes), reduce taxes for socially desirable behaviors (e.g., for voluntary employer provision of health care), and regulate persons and businesses whose activities may affect interstate commerce (e.g., manufacturers of pharmaceuticals and vaccines so that they are safe and effective).