Integration of America's health care and public health systems into a single aligned structure could trim costs and improve outcomes to secure the United States' place among the world's healthiest nations.
The past quarter of a century has challenged the United States with many public health emergencies, including H1N1, Ebola, COVID-19, and M-Pox among others. These infectious disease outbreaks have much in common. They all had implications for both health care and public health—triggering responses from hospitals, health systems, local, state, and federal public health entities.
Beyond infectious disease outbreaks, the nation's health care and public health sectors have been on the forefront of addressing the opioid epidemic and widespread mental health challenges—at least partially—stemming from the loneliness epidemic (PDF) and “diseases of despair.”
By aligning common vision, mission, and action anywhere these exist across the health care and public health sectors, a new aligned American health structure could help the nation meet these challenges. Past efforts at integrating health care and public health have only been partially successful and only in specific localities. It is time to systematically integrate these sectors across the United States, once and for all. Doing so would be in the best interest of both Americans' health and the nation's pocketbook.
Past efforts at integrating health care and public health have only been partially successful and only in specific localities. It is time to systematically integrate these sectors across the United States.
In the United States, the health care sector, consisting of hospitals, health systems, and other health care organizations, is tasked with diagnosis and treatment of health conditions on an individual patient-by-patient basis. The public health system, on the other hand, is tasked with disease prevention, population-level health education and promotion, and detecting public health emergencies at the community, city or county, state, or national levels.
Unfortunately for Americans, there exists a near century–old schism between health care and public health in the United States. The apparent lack of alignment between health care and public health has resulted in missed opportunities for shared data around infectious diseases, substance abuse disorders, and different forms of violence. An uncoordinated effort around health data collection and reporting can result in duplicated efforts and misallocation of related funding leading to wasted public and private funds.
Leveraging health care and public health resources to reach common goals can lead to more efficient and effective mechanisms of disease prevention, detection/surveillance, and treatment especially in situations where the two systems may capture different segments of given communities. For example, hospital-based emergency departments often interface with large numbers of unhoused individuals and the underinsured and uninsured who often use emergency departments as their only source of health care.
Some have attributed this historical divide between health care and public health to events and policies of the 20th century—such as the development of health insurance plans that reimburse health care services and the establishment of Medicare and Medicaid which focuses resources on the health care system as opposed to public health. Leaving public health out of these financial investments contributed to the divide between health care and public health that persists today.
Past and ongoing public health emergencies highlight the disconnect between the health care and public health systems and the costs associated with the lack of integration between the two sectors. For example, during both the COVID-19 pandemic and M-Pox outbreak the lack of coordination in guidance and public health messaging helped fuel misinformation and contributed to public distrust in these systems.
As early as the 1990s the American Public Health and American Medical Associations recognized the need to bridge this divide, but widespread and sustained collaborations between the two sectors did not materialize. Since 2010, through a provision of the Patient Protection and Affordable Care Act, the Internal Revenue Service requires hospitals that are tax exempt to conduct community needs assessments every three years in partnership with different community organizations—including public health entities.
Collaboration between primary care and public health has been the main focus of efforts to bridge health care and public health to date. An assessment of such programs in North Carolina, Oregon, Rhode Island, and Washington showed that such partnerships may help facilitate more efficient use of resources for health-related social screening and more effective connection of patients identified as needing resources with the related community programs. This assessment also identified the importance of the role of “visionary” leaders in both sectors to facilitate such partnerships, implementation of continuity plans to sustain the partnership, use of shared practice space and data systems, and adoption of Medicaid Managed Care programs (currently adopted by many states) to pay for community health services.
Another assessment focused on identifying essential elements (PDF) for integration of primary care, public health, and community organizations, showing the importance of appropriation of increased or new funding to support combined primary care, public health and population health efforts, Medicaid payment for health-related social needs, allocation of funding from the Centers for Medicare and Medicaid Services (CMS) for developing patient referral systems to community-based organizations, development of interoperable information systems to enhance data sharing between these systems, and CMS requiring the Accreditation Council for Graduate Medical Education to require primary care medical residency programs to collaborate with public health entities as a formal part of training.
Although many efforts across the country have focused on building collaboration between public health and primary care, there are missed opportunities in acute care settings. For example, an ongoing RAND study shows that many emergency departments engage in public health prevention, surveillance, and intervention. Such successful examples of health care and public health collaboration and integration should be captured and replicated broadly in the United States.
For example, some emergency departments offer influenza vaccines to their patients, others screen patients for suicidality or abuse, and some distribute Narcan to patients who present for opioid overdose to help reverse future overdoses. In fact, Florida's fiscal year 2024–2025 budget included a $3.5 million investment for improving diagnosis and treatment of Hepatitis C, HIV, and Syphilis by screening in emergency departments through a Florida Department of Health public-private partnership. Although disease surveillance is just one important public health role, these examples of public health functions in acute care settings demonstrate the feasibility of integration of health care and public health that could apply to other public health roles.
Similar opportunities exist in the inpatient hospital setting as demonstrated by the work of the Camden Coalition, a community-based nonprofit that works to improve the health of the residents of Camden, New Jersey. The Coalition works through a multidisciplinary, city-wide network that includes connecting residents to needed health care and social services when they visit Camden emergency departments or at bedside when residents are hospitalized in Camden hospitals.
Although many efforts across the country have focused on building collaboration between public health and primary care, there are missed opportunities in acute care settings.
To secure a healthy future for America, there are additional steps that should be taken to systematically integrate health care and public health that can increase efficiency, cost savings, and improved outcomes by closing the health care and public health gap:
- Develop integrated health care–public health data systems. To contain health care and public health costs, identify common disease surveillance goals across the two sectors and develop “combined” local, state, and national data systems to reduce redundancies and fill in existing data system gaps. Federal legislation may be needed requiring tax-exempt hospitals to provide access to their electronic health records to local health departments for use in public health needs assessment and to inform public health interventions.
- Build an integrated health care and public health infrastructure for chronic disease management. Establish an integrated framework for chronic disease education, prevention, and treatment by colocating public health services related to chronic disease within primary and acute care settings. This can be achieved by fostering partnerships between public health organizations and acute care facilities, supported by tax incentives for shared resources such as office space and information systems. Additionally, metrics for collaborative efforts between health care and public health can be linked to funding from CMS to encourage integration across sectors. It is also important to consider the need for federal legislation that mandates the identification and implementation of strategies to enhance collaboration and cooperation between the Centers for Disease Control and Prevention and National Institutes of Health. This collaboration should focus on identifying and funding critical research areas at the intersection of medicine and public health, thereby promoting system integration and alignment in the management of chronic disease.
- Develop an integrated workforce for health care and public health. In light of the significant workforce challenges faced by both (PDF) health care and public health sectors creating a shared workforce can help achieve common health goals, enhance efficiency, and potentially reduce costs for both sectors. One approach to this integration is to involve public health professionals in team-based health care workforces that health systems are establishing in both ambulatory care and acute care settings to optimize the existing workforce. Further, government financial incentives and/or requirements from accreditation boards for health care professions can promote cross-disciplinary training. This would encourage educational institutions to strengthen connections between schools of medicine and public health, particularly through opportunities for cross-disciplinary student experiences.
These measures can optimize the use of existing resources—including staff, space, supplies, equipment, and data/information systems—leading to more efficient and effective disease prevention and treatment. This optimization can enhance system efficiency, facilitate timely disease recognition, improve health outcomes, and generate cost savings for both health care and public health sectors, ultimately benefiting all Americans.
