Separating Health Care from Public Health Not the Way to Go


Robert Field's Check Up posting last week made a good point by arguing that cutting the budgets of the Centers for Disease Control and other public health programs is shortsighted and plainly dumb. What he didn't mention was that indiscriminate cuts to public health and scores of other social programs constitute the essence of Republican attitudes toward government. That approach consists of ignoring the well being among 98% of Americans in order to fund unconscionable tax cuts for the wealthy.

While defending the importance of public health as a government activity, Mr. Field drew a classic distinction between health care and public health. The former, he explained, involves individuals receiving treatment from doctors, nurses, hospitals and other professionals after they get sick. Public health, on the other hand, searches for underlying causes of malady and treatment approaches for entire populations.

That distinction sounds plausible enough until you start to really examine the two activities. It then becomes apparent that health care and public health are not distinct functions but, instead, represent parts of a seamless continuum in which specific activities of one often enter the domain of the other. When doctors and clinics administer yearly flu vaccines, are they practicing health care or public health?

What about a cardiologist in private practice, such as cardiologist David Becker of Flourtown, who assayed the leading brands of red yeast rice and found enormous variations in composition? When he used those results to develop a policy recommending that the FDA should regulate these supplements, much as its does prescription drugs, was Dr. Becker practicing health care or public health? In an interview he said the research was directly related to his practice because he wanted to see that his patients taking red yeast rice could obtain it with uniform quality.

When physicians at the Cleveland Clinic reviewed a series of studies and determined that Avandia raises the risk for heart failure, were they doing something altogether different than public health physicians at the FDA who reviewed studies and records to conclude that Vioxx caused 150,000 heart attacks and 50,000 deaths? We can look at countless examples among private practice physicians and public health agencies and ask, "Health care or public health?"

No, the analytical separation of public health from health care in the public mind was a deliberate campaign that organized medicine started early in the 20th century to transform the profession into a money-making guild. Professor Paul Starr of Princeton made the point in his classic study, The Social Transformation of American Medicine.

"[Organized medicine] has been worried about both competition and control. Private physicians have sought to keep government from competing with them, regulating their practice, or worst of all, incorporating medical care into the state as a public service like education. Their struggle to limit the boundaries of public health, to confine public medical services to the poor, and to prevent the passage of compulsory health insurance all exemplify these concerns."

In 1900 most practicing physicians had a hard time even earning a respectable living. At that time the only requirement to enter the Harvard Medical School was the ability to read and write. Within a generation organized medicine exercised the political muscle to make itself a well paid, highly esteemed profession. It did this by limiting the labor supply and stoking the mythology of a superior private market, even as it relied on transfer payments from government and the rise of a third health care sector, medical insurance companies, to generate its income.

Granted that Republicans claim reducing health care costs demands cutting the public health budget, but disputing such nonsense doesn't require buying into the myth that the two are different functions. The US spends far more per capita on health care than any other country, yet the World Health Organization ranks our overall quality 37th among the world's nations, our infant mortality 29th and life expectancy here places us at 34th. Part of the reason we spend more and get less for it is that organized medicine has been successful at fragmenting health care, thereby inserting physicians and insurers as profit-seeking middle men. As a clear example, 30% of all health care costs go to what's euphemistically called "administration." That consists not only of the profits extracted by insurance companies, but also the armies of payment specialists that every hospital, clinic and physician's office must employ to wrangle with their counterparts at the insurers. By contrast the administrative costs at Medicare are 3%.

Achieving the access, quality and cost control goals of any health care system requires recognizing that health care and public health must necessarily exist as a unified whole. Another necessary point requires abandoning the fiction that government is only capable of collecting statistics and administering care to charity cases. Health care is too important to exist primarily as a profit making opportunity where greed constitutes the underlying motive. By conjoining it with the historic approach to public health, this country can gain the benefits of both a market and a government operation.

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