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Swimming Upstream? Patient Protection and
Affordable Care Act and...
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control of community infections, educati...
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which are ...
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are directly related to the political le...
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of the medical profession and the medica...
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4386). HM Stationery Office, London. http...
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  1. 1. LWW/JPHMP PHH200276 January 13, 2011 17:21 Char Count= 0 Swimming Upstream? Patient Protection and Affordable Care Act and the Cultural Ascendancy of Public Health Kenneth DeVille, PhD, JD; Lloyd Novick, MD, MPH r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r After months of intense political infighting and widespread public interest and commentary, President Barack Obama signed the Patient Protection and Af- fordable Care Act (PPACA) into law on March 23, 2010.1 The law has been applauded by supporters, and at- tacked by critics, as the most comprehensive public health care reform in US history. Such attention is not misplaced. Its ultimate impact may very well rival that of Medicare and Medicaid passed more than 40 years ago.2 PPACA’s scope includes provisions aimed at in- creasing access to medical care, introducing cost con- tainment mechanisms into the public payer system (ie, Medicare and Medicaid), and reforming private insur- ance. As importantly, PPACA does not focus solely on physician-providedmedicalcaretoindividualpatients. Instead, the statute is suffused with provisions that promise to elevate the status of, and national commit- ment to, disease prevention, wellness promotion, and population-based interventions. Such an approach is not surprising. After all, Barack Obama’s 2008 “Plan for a Healthy American” boldly declared that cover- ing the uninsured was not enough: “Simply put, in the absence of a radical shift towards prevention and pub- lic health, we will not be successful in containing the costs or improving the health of the American people [emphasis added].”3 PPACA’s dramatic inclusion of traditional public health staples and doctrines has led executive director of the American Public Health Association, Georges C. Benjamin,4 to declare that “we are at a transformative moment in our social history. . .health reform provides us the opportunity to reshape the way we care for our- selves by not only expanding access to health services but shifting away from our ‘sick care’ system.” Simi- larly, Congressman Jim McDermott5 has observed that thepublichealthprovisionsofPPACA“indicateamove J Public Health Management Practice, 2011, 17(2), 102–109 Copyright C 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins toward making our system give priority to ‘health care’ rather than ‘sick care.”’ Koh and Sebelius6 of the De- partment of Health and Human Services forecast that PPACA “will usher in a revitalized era for prevention at every level of society.”(p1296) These comments and others like them suggest that PPACA has positioned the United States on the brink of a profound social change with respect to: (1) the “cul- tural authority” of public health and (2) the ways in which Americans and their government view and pro- mote “health.” It is true that the passage and provisions of PPACA send an undeniable signal that the dialogue regarding health in the United States has shifted in very real ways. PPACA and its provisions may in fact prove to the turning point, which both signals and nurtures the growing cultural authority of public health profes- sionals and academics. That result is far from guaran- teed and a number of factors will influence whether the near future will bring progress, or regress. ● Public Health Practice or Medical Care? While the dividing line between public health practice and medicine is often indistinct, the classic definition is frequently drawn from Winslow,7 who characterized public health as the following: . . . the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized com- munity effort for the sanitation of the environment, the Author Affiliations: Department of Bioethics and Interdisciplinary Studies, Adjunct Department of Public Health, Brody School of Medicine (Dr DeVille), and Department of Public Health, Brody School of Medicine (Dr Novick), Greenville, North Carolina. The authors thank Cynthia B. Morrow, MD, MPH and Leslie M. Beitsch, MD, JD for their insightful comments. Correspondence: Kenneth DeVille, PhD, JD, Professor, Department of Bioethics and Interdisciplinary Studies, Adjunct Department of Public Health, Brody School of Medicine, Greenville, NC 27858 (devillek@ecu.edu). 102 Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  2. 2. LWW/JPHMP PHH200276 January 13, 2011 17:21 Char Count= 0 Swimming Upstream? ❘ 103 control of community infections, education of the indi- vidual in principles of personal hygiene, the organiza- tion of medical and nursing services for the early diag- nosis and prevention of disease, and the development of the social machinery to assure everyone a standard of living adequate for the maintenance or improvement of health.(p30) Ordinarily, public health practice focuses on pre- ventive rather than curative approaches, on a popu- lation rather than on an individual basis. It is clear, though, that this dividing line is artificial and per- meable. Physicians in medical practice often offer preventive as well as curative care, and public health practitioners sometimes provide curative treatments to individual patients. The key inquiry for this discussion is not so much which practitioners provide health care butratherfromwhatperspectivearehealthquestionsin policy and practice addressed—from the public health, or the individual medical care, model—and whether the tendency toward one approach or the other is evolving. ● Prevention and Wellness Provisions in PPACA In that it purports to improve the health of the nation, the PPACA of course might be viewed as a public health document. The framers of the act include a wide array ofsubstantialandspecificmeasuresaimedatfurthering the public health approach to wellness and prevention.8 Onlyarepresentativesamplingisrequiredhere.Oneset of provisions requires coverage of preventive services in the clinical setting. Newly issued group-health and insurance-plan policies (included employer-provided insurance) are prohibited from requiring cost-sharing (mainly co-payments) on a wide range of screening and preventive medical care measures.9 Mandated coverage includes measures with an “A” or “B” rating from the US Preventive Services Task Force; immunizations10 ; Health Resources and Services Administration (HRSA) sanctioned preven- tive care screenings for infants, children, and ado- lescents; and certain HRSA-endorsed screening for women.11 PPACA also eliminates co-payments on a class of preventive services for Medicare and Medi- caid recipients.12 Under Medicare, providers will be reimbursed for annual wellness visits during which comprehensive “personalized prevention plans” will be created.13 Another PPACA provision allows employ- ers who provide group health insurance to give their employees discounted premiums if they participate in wellnessprograms.14 Employerswillberequiredtopro- vide a break time for nursing mothers for 1 year after delivery,15 and chain restaurant and vending machine companies must post nutritional content of all menu items.16 On a larger scale, PPACA establishes a “Prevention and Public Health Fund” under the Department of Health and Human Services to support public health programs, including research, education, screenings, and immunization. The fund was provided an initial appropriation of $500 million with increasing appro- priations thereafter.17 The legislation created a National Prevention, Health Promotion and Public Health Coun- cil, chaired by the surgeon general to coordinate fed- eral wellness and health promotion activities and to advise the president on the most pressing public health problems.18 The Department of Health and Human Ser- vices is required to initiate a broad-based education program focused on prevention, and health plans will be required to develop ways to collect data, evaluate them,andreporthowhealthoutcomescanbeimproved by preventive measures and quality improvement ac- tivities. PPACA authorizes the creation of loan repay- ment programs specifically designed to increase the public health workforce. Under the rubric of “Creating Healthier Communities” PPACA authorizes Congress to sponsor grants at the state level to aid public health agencies in data collection, education, screening, and treatment in a wide range of areas and populations. Fi- nally, PPACA will require data collection and analysis to identify health disparities. ● Prevention and Population Health: Has the Time Come? The sheer number these and other PPACA provi- sions signal an unprecedented appreciation for public health–related remedies and philosophy. The fact that many of the prevention provisions of PPACA received bipartisan support while other aspects of the act were bitterly contested also suggests at least a partial change in political consciousness when it comes to legisla- tive support for the public health approach. But mixed signals abound, and the question of the depth and the staying power of the public health mentality-shift remain. As a practical matter, the ultimate impact of the pub- lic health provisions in PPACA will depend heavily on the implementing regulations that must be drafted by the relevant agencies and the degree to which fu- ture appropriations support the apparent promise of the legislation. In “Restoring Health to Health Reform,” Jacobson and Gostin19 applaud the historic importance of PPACA but sound several notes of caution. Perhaps, most importantly, the real world impact of the pro- visions will depend on future appropriations, few of Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  3. 3. LWW/JPHMP PHH200276 January 13, 2011 17:21 Char Count= 0 104 ❘ Journal of Public Health Management and Practice which are guaranteed. While grants to state and lo- cal public health organizations are authorized by the PPACA, effectiveness of the program will depend on whether these future dollars materialize. The creation of the Prevention and Public Health Fund potentially represents the largest infusion of capital into the pub- lic health infrastructure in U.S. history. Some public health advocates were disappointed to discover, how- ever, that nearly half of the first year’s $500 million allocation was diverted to funding health professions programs, rather than to activities that serve more di- rectly population-health concerns. Jacobson and Gostin note that PPACA provides loan repayment programs to buttress the public health workforce, but lament that the legislation “otherwise does not provide sustainable and scalable resources to revitalize the public health structure” at the state and community levels. Similarly, Jacobson and Gostin are sensitive to the scant atten- tion devoted in PPACA to reducing social disparities that affect health. Similarly, the legislation’s attack on health disparities seems limited to targeted attempts to changing lifestyle and health behaviors at the indi- vidual or community level through a series of grant- funded initiatives. It does not acknowledge, implicitly or explicitly, the importance of developing strategies to influence the social determinants of health. There is a growing recognition that social determinants exert a powerful influence on the comparatively poor state of health in the US compared to other industrialized na- tions. Our willingness to implement policies to affect these determinants is absent in this legislation, in con- trast to certain European countries, as will be discussed later. As a result, Jacobson and Gostin conclude that de- spite its extensive concern for prevention and wellness, “PPACA takes the existing system as a given and does little to change the fundamental dynamic of how public health is organized, financed, and delivered.”19(p86) ● Swimming Against the Current? While PPACA does boast a prominent preventive agenda, realization of a broad-based public health ap- proach may require swimming upstream against the currents of US history, contemporary US culture, and existing political realities. Unlike Europe, Canada, Swe- den, Finland, and the UK, the public policy environ- ment in the United States may slow implementation of the preventive initiatives pioneered in PPACA and delay indefinitely the acceptance of more expansive and sophisticated public health visions. Growing in- equalities in income and wealth combined with Amer- icans’ generally and deep-seated negative attitudes to- ward the role of government, do not provide fertile soil for an activist and forward-looking public health agenda. Beauchamp20 recognizes that cultural factors often translate into practical barriers to government protection of the health and safety of the public? The dominant language of American political discourse, Beauchamp observes, has long been individualism, does not support for the benevolent restriction of vol- untary conduct. Government prescriptions of life-style choices, so-called public health paternalism, remain an anathema in many regions of the United States. One provision of PPACA requires chain restaurants to pro- vide nutritional content for food sold to customers, an area of regulation still viewed with special suspicion by many US citizens. One of the authors (LN) served previously as commissioner of health for a county in upstate New York. Frequently he was intimately in- volved in contentious discussions with county legisla- tors who vehemently contended that indoor smoking prohibitions were harbingers of “telling us what to eat at fast-food establishments.” JonathanOberlander21 hasruefullyobservedthat“In the United States, the more desirable health care reform is on substantive grounds, the less politically feasible it is.” The history of motorcycle legislation in the United States seems to exemplify Oberlander’s observation and lament. Despite overwhelming evidence that oper- ator and passenger helmets reduce deaths and injuries, they are currently required in only 20 states.22 Federal efforts, over the last 3 decades, to encourage states to enact these laws have failed, and, where such laws ex- isted, motorcycle advocacy groups have been broadly successful in repealing them. Jones and Bayer23 reason, understandably, that this history raises troubling ques- tions about the realistic possibility of implementing a thoroughgoing culture of public health that relies heav- ily on government to protect individuals from their own choices, even in the face of strong evidence that these behaviors result in higher levels of morbidity and mortality. The cold realpolitik truth is that the funding and implementation of the provisions of PPACA will de- pend far more on the breadth, depth, and duration of public support than on the well-meaning, scientif- ically verified recommendations and exhortations of public health authorities and academics. Attacks on PPACA public health provisions have already begun. The Johanns Amendment (SA 4596), offered even be- fore the fall elections of 2010 for example, proposed to eliminate nearly all of the funding for the Preven- tion and Public Health Fund of PPACA.24 Although the Johanns Amendment ultimately failed, it is emblem- aticoftheinherentvulnerabilityofPPACA’sprevention initiatives. Moreover, it is axiomatic that the conditions under which public health initiatives will flourish or wither Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  4. 4. LWW/JPHMP PHH200276 January 13, 2011 17:21 Char Count= 0 Swimming Upstream? ❘ 105 are directly related to the political leanings of the par- ticular government currently in power. The vicissitudes ofgovernmentalchange,especiallyintheUnitedStates, aggravate this reality. International comparisons are instructive. Consider Canada. Two provinces, Quebec and British Columbia, were early leaders in champi- oning broader concepts of health. Later governments, dominated by political conservatives, downplayed of policies and programs specifically designed to enhance the population’s health and health promotion.25 The dramatic shift in power from Democrat-to-Republican in the 2010 US mid-term congressional elections will undoubtedly affect the degree to which a consistent public health approach is pursued at the federal level. Observers doubt that an outright repeal of PPACA is forthcoming, however, Republican leaders seem poised to blunt the impact of the legislation by failing to fund what they view as objectionable provisions.26 It is un- clear at this point how this strategy will affect the public health provisions of PPACA. In contrast, countries with ideologically consistent governments have typically been able to stay-the- course in advancing and developing coherent public health policy agendas, especially when the underlying social culture is supportive of such approaches. The apparent results are arresting. Sweden, for example, boasts extraordinarily low levels of infant and child- hood mortality from injury.27 Swedish life expectancy is ninth highest in the world. These health successes have been achieved even though the gross domestic product per capita is relatively low, 17 of 30 among eco- nomic cooperation and development nations.27 Signifi- cantly though, Sweden has low levels of child poverty, low unemployment and very high levels of public so- cial expenditure. Income inequalities remain low.28 In addition, social welfare policies implemented in Swe- den during the 1920s have long been institutionalized into Swedish government and internalized by Swedish society. This orientation has enabled Swedish public health officials and the population, to be receptive to new and broader perspectives, developments and in- novations in health promotion. In the US, activities of public health agencies and social welfare policies have been artificially compartmentalized undermining coor- dinated attempts to address the social determinants of health. Raphael suggests that public health has been charac- terizedby2dominantmodels.27 Thefirst,thetraditional model (represented as well by PPACA) focuses on biol- ogy, controlling contagious diseases and managing risk behaviors and factors including weight, diet, tobacco use,cholesterollevels,andsexualpractices.Thesecond, more recent, model focuses as well on what has become known as the “social determinants” of health. This view of health promotion holds that the health and illness of populations are affected not only by medical care and lifestyle choice but also by a wide array of social factors, including income, housing, education, human rights, and social status and income disparities. According to this line of analysis “The stark fact is that most disease on the planet is attributable to the social conditions in which people live and work.”29(e445) While individual health can sometimes be traced fairly directly to tra- ditional biomedical causes, population health is corre- lated to the social determinants of health. The social determinants of health approach to population health has found far more receptive homes in those cultures and governments that have a long-standing, stable, and consistent commitment to public health in general. Again drawing on the Swedish example, Welfare in Swe- den: The Balance Sheet for the 1990’s (2002) highlights the concern of the Swedish government for general, over- arching societal well-being. Welfare in Sweden focuses its attention and commitment on broad social determi- nants, which are increasingly viewed as the foundation of health inequalities.30 A focus on social determinants also distinguishes the Swedish approach from public health provisions in PPACA, which emphasize almost solely important, but limited, preventive health mea- sures, clinical preventive services, health behaviors and community health initiatives. Similar to Sweden, but in contrast to the United States, the United Kingdom has demonstrated a long- standing concern with class-related inequality. The Black Report (1980) revealed that despite a generation of universal medical care, health inequalities remained or actually increased.27 The Black Report and similar recommendations were ignored for nearly 2 decades. Until 1997 when the new Labour Government imple- mented a series of policy recommendations embracing both models of public health improvement: (1) address- ing the social determinants and (2) risk behaviors and factors.31 Britain’s first Minister for Public Health was appointed and according to a Labour Party manifesto: “A new minister for public health will attack the root causes of ill health, and so improve lives and save NHS money. Labour will set new goals for improving the overall health of the nation, which recognise the im- pact that poverty, poor housing, unemployment and a polluted environment have on health.”32 Similarly, Re- ducing Health Inequalities: An Action Report (1999), pro- duced by the Department of Health in the UK, included specific policies on health determinants of living stan- dards, education, employment, housing, and building healthy communities.33 In the white paper Saving Lives: Our Healthier Nation, the UK government issued the most explicit approach taken by any European govern- ment to improve public health.34 Prime Minister Tony Blair, in its forward, lauds the importance of exercise, eating properly, and not smoking, and a strategy for Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  5. 5. LWW/JPHMP PHH200276 January 13, 2011 17:21 Char Count= 0 106 ❘ Journal of Public Health Management and Practice population prevention was outlined including a con- tract to reduce the death rate from heart disease and stroke among people younger than 65 years by at least one-third.35 What happened next in the United Kingdom is most instructive and illustrative of the changing fortunes of public health, even in a country that has tradi- tionally been receptive to such concerns. By 1999, the newly created position of Minister for Public Health, initially filled by Tessa Jowell, was downgraded to the lowest ministerial rank: parliamentary under sec- retary, diminishing its stature and influence.36 Jow- ell’s successor carried neither the rank nor the back- ground in social policy to spearhead the ambitious agenda articulated merely 3 years previous.37 Con- currently, enthusiasm and commitment seemed to wane for the health inequalities reduction program. As McKee31 points out the “government and its health department have yet to show that tackling inequali- ties in health are as important as reducing NHS wait- ing lists and developing specialty care for people with cancer, heart disease, and mental illness.” Thus, pub- lic health is frequently assigned lower priority even in single-payer systems in which healthcare and health promotion might be more easily integrated. The parallels with the future role of prevention in the US health care reform are important. Consider the stop-and-start progress of public health reform in the United Kingdom, a country, which, unlike the United States, is characterized by a long tradition of public health concern and sensitivity to the social determi- nants of health. Currently in the United States, broad- based public health concerns cannot compete with society’s concern with the status of individual medi- cal care or the advocacy of the health-related indus- tries of insurance, hospitals, and pharmaceutical com- panies. What will be the staying power of even the prevention initiatives when turbulence arises with the many medical care issues that will be engendered by PPACA? ● The Practical Implications of “Cultural Authority” and the Battle for Hearts and Minds As noted, the promise of PPACA can only be fulfilled if the regulations that will actually operationalize its provisions embody a broader vision of health care, dis- ease prevention, wellness promotion, and population- based remedies. Both the content of the regulations and the amount and placement of future funds will depend on what might be labeled as the “cultural authority” of public health, and the degree to which Americans and their government view “health care” as something broader than merely medical care for sick individuals. In the United States, “medical care” and physicians have become associated with individual patients, cures, and focused scientific remedies. In contrast, “public health” has been associated with population-health, prevention, and the remediation through policy and ed- ucation of unhealthy conditions.38 For a variety of rea- sons, physicians were said to have achieved “cultural authority” in the first one-third of the 20th century. This cultural authority, as well as growing technical and sci- entific competence, played a key role in the American public’s acceptance of the use of physicians to provide their medical care.39 As importantly for this discussion, the medical profession’s cultural authority assured the public’s acceptance of the medical profession’s opin- ion and perspectives on disease, health, health care, and policy. As a result, physicians not only dominated health care delivery but also “enjoyed a correspond- ing power in the domain of ideas.”40(S26) The success of physiciansinestablishingthissociallegitimacyandcul- tural authority incidentally undercut the ability of other health professionals and perspectives to influence pub- lic opinion, governmental action, concepts of health, and health care. The public health perspective in the United States has matured scientifically and conceptually over the last century, but it has heretofore failed to command the attention or respect accorded to physician-driven sci- entific medicine. But, there are signs of change. PPACA after all, includes a far larger number of public health– related initiatives than did the failed Clinton Health Care plan of 15 years ago. Recent historical factors and indicators have undoubtedly broadened the public’s view of health and health policy. A growing under- standing and acceptance by the public of the behav- ioral and environmental determinants of health has increased public support both for regulation and for voluntary, culturally driven lifestyle changes. Nearly 4 decades of rising medical costs and expenditures have increased the interest in and commitment to preventive health measures in general. Finally, public awareness of the multiple threats of both bioterrorism and pandemic flu in the last decade have highlighted the insights and tools that public health theorists and professionals can offer the country.40 Despite these indicators suggesting a consciousness change in Americans’ attitude toward public health activity and philosophy, there are reasons to believe that the transformation, while underway, will remain at least incomplete for some time. By almost any estimation, the public health approach is still at odds with the still widespread and resilient notions of individualism, personal responsibility, and limited government among many in the United States. The rise Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  6. 6. LWW/JPHMP PHH200276 January 13, 2011 17:21 Char Count= 0 Swimming Upstream? ❘ 107 of the medical profession and the medicalized view of health were based partially on the US public’s confi- dence and attraction to the biomedical approach to un- derstanding and treating sickness and disease. This ap- peal has persisted long after it has become clear that the purely biomedical approach to disease and illness cannot address fully the reality of environmental and multicausal agents. As long as popular culture’s view of sickness and health is dominated by the pure biomed- ical approach, its understanding and confidence in the public health model will remain incomplete. In this re- spect, it becomes more difficult to believe that PPACA is a revolutionary document that represents irrevoca- ble cultural change or an absolute endorsement of the public health philosophy and approach. Similarly, while public engagement in the PPACA debate was unprecedented, attention focused largely on the issues of access to medical care, insurance, and costs—not on the substantial public health and pre- vention components of PPACA. As mentioned earlier, PPACA incorporated only some of the important in- sights of contemporary public health. For example, Judy Monroe, deputy director for Centers for Disease Control, recently ranked the factors that, the CDC be- lieves, most affect health. From smallest-impact-on- health-to-largest, these factors include counseling and education, clinical interventions, long-protective inter- ventions, changing the context to make individuals’ de- fault decisions healthy, and socioeconomic factors (the social determinants of health).41,42 Despite the identifi- cation of “socioeconomic factors” and “changing the context” as the most efficacious measures, PPACA pro- visions focus predominantly on the factors labeled as having the smallest impact, namely: clinical interven- tions, counseling and education, and protective inter- vention. It cannot be denied that the aforementioned prevention activities are important to the health of individuals, but coupling them with broader social and environmental health determinant intervention is necessary for maximal improvement in community health status. Similarly, the Association of State and Territorial Health Officials recently sponsored a con- ference titled “Making Health Reform More Than Sick Reform: Shifting the Focus to Better Population Health” in which attendees could expect to “Find out the ways in which federal health reform will attempt to shift the current U.S. healthcare ‘non-system’ from its sole focus on medical care and insurance reimburse- ment, to a more rational system aimed at population- based health and wellness.” Despite the apparent promise of conference theme, the titles of the con- ference presentations largely focus on preventive and public health remedies delivered in the medical care setting.43 ● Conclusion In sum, when the US Congress passed PPACA in March 2010, something important happened, although it is far less than a paradigm shift. To the extent that legislation in a republican political system is presumed to reflect in some way the public will, the inclusion of dozens of public health initiatives in PPACA and a reliance on public health philosophy in the legislation seem to suggest that a change in society’s attitude may be un- derway. But dramatic legislative action is not always predicated on an equally dramatic cultural transforma- tion. Legislators, after all, respond most readily to or- ganized interest groups and opinion leaders who help shape the content of the legislation, rather than reflect directlybroad-basedculturalrevolutions.Onceinnova- tive legislation is in place, cultural change may, or may not, follow. For example, in pioneering civil rights leg- islation, in privacy protections, in safety and consumer safety measures, dramatic legislative and regulatory ac- tion preceded, instead of followed, the transformation in public attitude. Consciousness sometimes precedes political change, but political action sometimes inspires consciousness change. A similar dynamic may under- way here. Public discourse before and after passage of PPACA was predominantly focused on access and cost issues associated with the delivery of traditional medical care within the traditional physician–patient relationship—a sign that public concern is not currently focused on public health initiatives. Nevertheless, pub- lic health activists and groups were deeply engaged in the drafting of the health reform bill. According to Jeffrey Levi,44 Director of Trust for America’s Health, a consortium of scores of public health groups “spoke with one voice” and were able to influence the final legislative product in a way never before possible. The resulting legislation represents both a symbolic victory for the public health approach and a very real oppor- tunity to advance the public health agenda if the im- plementation regulations and expropriations match the word and apparent intent of the PPACA provisions. In addition, the entitlement to such preventive care may in time transform the public’s understanding and respect for such measures in a broader context. But such change will require social conversion, and will take time. PPACA may ultimately represent a defining moment, a crossing-over-the-Rubicon beyond which there will be no return to old modes of think- ing and behavior when it comes to health and health promotion. But that result is not foreordained. What individuals think about health influences their incli- nations towards health services.45 Individuals consult physicians because of their perceived susceptibility and vulnerability to illness.46 In contrast, the public does not Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  7. 7. LWW/JPHMP PHH200276 January 13, 2011 17:21 Char Count= 0 108 ❘ Journal of Public Health Management and Practice experience the immediacy of public health activities: “Turning on any kitchen faucet for a glass of drink- ing water without hesitation or peril is a silent homage to public health success, which would not have been possible at the start of the 20th century.”47 The key term here, of course, is silent homage. The spending of state and local public health agencies constitutes only 2.4 percent of all US health care spending.48 Follow- ing 9/11 and the apparent looming threat of bioterror- ism, public health agencies had a new public health protection role. Many public health officials believed that a new era with new resources was on the hori- zon. Although additional resources for public health preparedness were initially forthcoming from the Cen- ters for Disease Control and Prevention, sharp reduc- tions in the availability of these funds followed as soon as public attention waned. The transient nature of po- litical power in the United States and the vulnerabil- ities borne of difficult economic times will also be a continuing challenge as we swim upstream. For now, as Koh and Sebelius6 suggest, a modest “Moving pre- vention toward the mainstream of health may well be one of the most lasting legacies of this landmark legislation.” REFERENCES 1. Patient Protection and Affordable Care Act, Pub. L. No. 111- 148 (2010). 2. Silberman P, Lia CE, Ricketts TC. Understanding health re- form: a work in progress. N Carol Med J. 2010;71(3):215-231. 3. Obama’08. 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