The National Advisory Committee on Rural Health, February 2000 i

The National Advisory

Committee on Rural Health

February, 2000

Rural Public Health:

Issues and Considerations

A Report to the Secretary

U.S. Dept. of Health and Human Services
The National Advisory Committee on Rural Health, February 2000 ii

Project Consultant and Primary Author

Rhonda Johnson

Research Associate

North Carolina Rural Health Research and Policy Analysis Program

The Cecil G. Sheps Center for Health Services Research

The University of North Carolina at Chapel Hill

Contributing Editor

Thomas F. Morris

Policy Coordinator

Federal Office of Rural Health Policy

Health Resources and Services Administration

U.S. Department of Health & Human Services

Rockville, MD 20857
The National Advisory Committee on Rural Health, February 2000 iii

The National Advisory Committee on Rural Health

Chartered in 1987, this fourteen-member citizen’s panel of nationally recognized rural health

experts advises the Secretary of Health and Human Services on ways to address health care

problems in rural America. Chaired by former Iowa Governor Robert D. Ray, the

committee’s private and public-sector members reflect wide-ranging, first-hand experience

with rural issues - in medicine, nursing, administration, finance, law, research, business, and

public health.
The National Advisory Committee on Rural Health, February 2000 iv

The National Advisory Committee on Rural Health

Outgoing Chair

Robert D. Ray

Former Iowa Governor

Des Moines, IA

Incoming Chair

Nancy Kassebaum Baker

Former U.S. Senator

Burdick, KS

Members

* Member of the Public Health Task Force

** Chair of the Public Health Task Force

J. Graham Atkinson, D.Phil.

Health Care Financial Consultant

Washington, DC

H.D. Cannington

Chief Financial Officer

Emanuel Medical Center

Swainsboro, GA

William H. Coleman, M.D., Ph.D.

Practicing Physician

Scottsboro, AL

Shelly L. Crow *

Clinic Administrator

Eufaula Indian Clinic

Eufaula, OK

Barbara Jean Doty, M.D. *

Associate Director

Alaska Family Practice Residency

Wasilla, AK

Jennifer Frary, P.A.-C.

Occupational Health Management

Wyoming Medical Center

Casper, WY

Faye Gary, R.N., Ed.D. *

Professor

University of Florida

College of Nursing, JHMHC

Gainesville, FL

Alison M. Hughes * **

Associate Director, Rural Health Office

University of Arizona College of

Medicine

Tucson, AZ

Louis P. Lerma

Chief Executive Officer

Clinicas de Salud del Pueblo, Inc.

Brawley, CA

Thomas Scott Nesbitt, M.D., M.P.H. *

Acting Assistant Dean for

TeleHealthOutreach and Special

Projects Telemedicine, Rural Health and

Hospital Affiliations

U.C. Davis Medical Center

Sacramento, CA
The National Advisory Committee on Rural Health, February 2000 1

Frank Scott Newman, Ph.D.

Professor Emeritus

Veterinary Virulogy and Medical Science

Montana State University

Retired Director

Montana State Office of Rural Health

Ekalaka, MT

E. Jay Wheeler, M.D., Ph.D.

Professor and Chairman

Department of Health Organization

Management, Texas Tech University

Health Sciences Center, School of Medicine

Lubbock, TX

Executive Secretary to the Committee

Wayne W. Myers, M.D.

Director

Federal Office of Rural Health Policy

Health Resources and Services Administration

U.S. Department of Health & Human Services

Rockville, MD 20857
The National Advisory Committee on Rural Health, February 2000 2

Preface

As the American health care system continues through dramatic change, there has been a

renewed focus on how to ensure the continued viability of the public health system. In

particular, the concern has been centered on what might best be defined as the public health

infrastructure. This catch-all term, for the purpose of this report, refers to a wide range of

connected issues related to public health from the training and education needs to the funding

streams that sustain it. These concerns are being felt across the public health spectrum but are

particularly pronounced in rural areas, where the local health departments are often isolated

and understaffed. In September of 1998, the National Advisory Committee on Rural Health

decided to examine the impact of these changes on the rural public health infrastructure. This

report, which is the product of that effort, is intended to bring a rural focus to a larger

national issue and frame some of the crucial issues that specifically affect the viability of the

rural public health infrastructure. Further, it serves as a resource for the Committee should it

choose to make any recommendations to the Secretary on ways to improve the rural public

health infrastructure.
The National Advisory Committee on Rural Health, February 2000 3

Core Public Health Functions

ASSESSMENT: The regular systematic

collection, assembly, analysis and dissemination

of information on the health of the community.

Assessment practices are specifically to:

! ASSESS the health needs of the

community,

! INVESTIGATE the occurrence of health

effects and health hazards in the

Community, and

! ANALYZE the determinants of identified

health needs.

POLICY DEVELOPMENT: The development of

comprehensive public health policies by

promoting the use of scientific knowledge base in

decision-making. Policy development practices

are specifically to:

! ADVOCATE FOR PUBLIC HEALTH, build

constituencies and identify resources in the

community,

! SET PRIORITIES among health needs, and

! DEVELOP PLANS and policies to address

priority health needs.

ASSURANCE: Assure constituents that services

necessary to achieve agreed-upon goals are

provided by encouraging actions of others (private

or public), requiring action through regulation, or

providing services directly. Assurance practices

are specifically to:

! MANAGE RESOURCES and develop

organizational structure,

! IMPLEMENT programs,

! EVALUATE programs and provide quality

assurance, and

! INFORM AND EDUCATE the public.

(Dyal, 1991; Turnock and Handler, 1992 )

Public Health Overview: A Time of Transition 

Public health is often referred to as

the foundation of the health care

system, but many signs point to

emerging structural problems. Recent

reports document the steady

deterioration of the national public

health system. Health departments are

closing. Technology and information

systems are outmoded. Emerging and

drug-resistant diseases threaten to

overwhelm resources and serious

training inadequacies threaten the

capacity of the public health

workforce to address new threats and

adapt to changes in the health care

market. (Medicine and Health

Perspectives, 1998).

Despite these concerns, there is little

consistent public outcry from the

public to fix a system that often isn’t

missed until it’s gone. The

consequences of a continued

weakening of the public health

system, however, aren’t as easy to

explain away. Public health

professionals say they could lead to

more widespread outbreaks of

infectious diseases and slower

response times by health care

professionals to emerging threats.

The perceived instability of the public

health infrastructure is part of the

larger debate and persistent ambiguity

about the appropriate roles and

responsibilities of ‘public health.’ More than ten years ago, the Institute of Medicine released

a paper on The Future of Public Health that identified the mission of public health as

‘assuring conditions in which people can be healthy,’ and conceptualized three core public

health functions: assessment, assurance and policy development. (IOM, 1988).

The move toward local implementation of these public health functions, as well as the rapid

expansion of managed care have forced a change in the traditional roles of local health
The National Advisory Committee on Rural Health, February 2000 4

Ten Essential Public Health Services

1. Monitor health status to identify community

health problems

1. Diagnose and investigate health problems

and health hazards in community

1. Inform, educate, and empower people about

health issues

1. Mobilize community partnerships to identify

and solve health problems

1. Develop policies and plans that support

individual and community health efforts

1. Enforce laws and regulations that protect

health and ensure safety

1. Link people to needed personal health

services and assure the provision of health

care when otherwise unavailable

1. Assure a competent public health and

personal health workforce

1. Evaluate effectiveness, accessibility, and

quality of personal and population-based

health services

1. Research for new insights and innovative

solutions to health problems

(Public Health in America, PHFSC)

departments in rural areas (Moscovice, et al, 1998). Yet the challenges faced by such

departments are just part of the larger picture of public health infrastructure instability.

Diminished funding, and fragmentation

of public health responsibilities have all

contributed to this instability. Between

1990 and 1993, the percentage of the

nation’s health care dollars spent on

public health declined from 2.7% to

1%. With expansion of managed care,

devolution of governmental

responsibilities, and restructuring of

state agencies, public health agencies

have had to rethink many of their

traditional roles and responsibilities.

Health departments have long played a

key role in shoring up the health care

safety net, that group of private and

public providers that disproportionately

care for the poor and uninsured. Now,

these health departments are also being

asked to refocus on the traditional core

public health activities.

This is problematic because health departments have become more involved in direct clinical

care during the past 20 years, particularly for Medicaid beneficiaries. These clinical

reimbursement dollars became very important to the overall support of the agencies. This

strategy was particularly attractive to state and local funding entities because Medicaid

payments include large proportions of federal funds, which lessened state funding pressure.

In those areas were Medicaid paid on an actual cost-basis, the health departments were able

to include many of their administrative costs in their clinical care budgets.

These dollars helped subsidize core public health activities and, in some cases eventually

largely supplanted existing funding sources for core public health functions. States only

began to worry when they started seeing growing Medicaid expenditures. Many moved their

Medicaid populations into managed care plans, which did not contract with health

departments to continue providing those services. That meant the loss of Medicaid revenues

for the health departments and fewer dollars to cover traditional public health duties.

Funding shortfalls are only part of the problem for the deteriorating public health

infrastructure, though. The Public Health Foundation reports that only 15 percent of the

nation’s public health workforce has received academic education in public health. That

creates a significant workforce challenge for local health departments given the call for a

return to core public health activities called for by the IOM. Recruitment and retention of

qualified public health workers continues to be a problem, particularly in rural areas. And
The National Advisory Committee on Rural Health, February 2000 5

Did You Know...

! About 3000 local public health agencies,

boards and departments make up the heart

of the public health system; 2/3 of these are

in small towns with populations of less than

50,000. (National Association of County and

City Health Officials)

! In 1996, a survey by the National Governor’s

Association (NGA) found that 27 out of 49

states planned to redirect resources from

direct provision of services (medical) to

performance of core public health functions.

Michigan and Oregon no longer provide any

direct services.

! In 1995, the Committee for the Improvement

of Public Health in Montana conducted a

survey of local public health agencies, and

found that most agencies had the ability to

perform fewer than half of six core public

health functions and services. (Frontier

Education Center, 1999).

! Less than half of the public health workforce

have had training in public health. Less than

half of the nation’s local public health

agencies have the capacity to provide the

essential public health services. (U.S.

Department of Health and Human Services,

Draft Document, 1998)

while technology and distance learning offer great potential possibilities, the rural areas in

most need of these services are the least equipped to take advantage of them.

All of these influences have created an increasingly fragile infrastructure during a time of

great change. Both the states and the Federal governments find themselves dealing with

budget surpluses for first time in many years, but few extra dollars are being committed to

public health concerns. A recent survey of state health agencies demonstrated limited

progress and much room for continued effort and improvement in implementation of IOM

recommendations (Scutchfield, Beversdof, Hiltabiddle, and Violante, 1997). One core

function, policy development, had actually declined in some agencies since 1989.

As expected, professional associations are expressing concern about basic infrastructure

issues. In 1994, the American Public Health Association (APHA) picked the enhancement of

the federal, state, and local public health infrastructure as one of its two priorities for

legislative action, and also lobbied for expansion of both medical care services and public

health programs to improve the nation’s overall health status (Trevino and Jacobs, 1994).

Chapter 7 and 14 of the draft Healthy

People 2010 report is exclusively

devoted to supporting a strong and

responsive public health system as a

critical foundation for all other

objectives. In fact, the infrastructure

goals and objectives described in the

report drive the ability to support the

other 25 priority areas. Yet calls to

support the infrastructure often fall on

deaf ears. At the same time, there is no

corresponding cry for help from the

general public, which has trouble

relating to a service that is largely

invisible to the masses.

Any attempt to address these core

infrastructure issues is made even more

difficult by the fragmented nature of our

current public health system. At least six

different federal agencies (The U.S.

Department of Agriculture, the Centers

for Disease Control, the National

Institutes of Health, the Administration

for Children and Families, and the

Health Resources and Services

Administration, and the Environmental

Protection Agency) all have major funding responsibility for various public health activities.

Each of the 50 states also devote significant financial resources to public health as do
The National Advisory Committee on Rural Health, February 2000 6

individual counties. These myriad funding sources create a confusing minefield of different

priorities and guidelines that must be navigated by local health departments.

Rural public health departments feel the same strains as their urban counterparts. In many

ways, however, these issues are even more challenging in rural areas. This is because rural

public health departments face the added challenge of having even fewer resources coupled

with geographic isolation and a lack of educational and training support. While there has

been a fair amount of research and discussion about general public health infrastructure

issues, there has been little attention given to the rural dimensions of this topic.

This paper will attempt to bring a rural focus to some of these key public health infrastructure

issues and to provide the background material to the Committee should it decide to make any

recommendations to the Secretary. Specifically, the report will focus on the rural aspects of

the following issues:

! Leadership:

! Workforce Preparedness

! The Safety Net:

! Impact of Managed Care:

! Telecommunications:

! Funding:
The National Advisory Committee on Rural Health, February 2000 7

Public Health Resources

! Turning Point, a program of the WK Kellogg

Foundation and the Robert Wood Johnson

Foundation is designed to transform and

strengthen the public health infrastructure in

the US. Concurrently, up to 60 local public

health partnerships in those states receive

funding for capacity-building, planning, and

leadership activities for up to three years.

Contact information: Bobbie Berkowitz,

National Program Director. Tel: 206-543-

8410 Fax: 206-616-8466

gomenn@u.washington.edu.

! Institute of Medicine, (1996). Healthy

Communities: New Partnerships for the

Future of Public Health. Washington, DC.

National Academy Press. This follow up

report to the Future of Public Health

addresses two additional critical public

issues: 1) the relationship between public

health agencies and managed care

organizations, and 2) the role of the public

health agency in the community. (IOM,

1988)

Leadership 

A void in public health leadership

on rural issues may be

exacerbating current problems.

There are few real rural voices taking part

in the policy discussions and decisionmaking processes that shape the public

health infrastructure. This is often true at

both the state and Federal level and there

are several factors at work that are

responsible for this situation. One is the

changing demographics of our

communities. As rural areas continue to

lose population relative to the urban and

suburban areas, there is also a

corresponding loss of political power in

state legislatures. Many state governing

bodies used to be dominated by their rural

members. These rural voting blocks held

great sway in many states and ensured that

rural communities had a place at the

decision-making table. As the voting

power has shifted toward urban and

suburban-areas, rural communities have

lost political power.

At the same time, there has been no effective lobbying organization devoted solely to rural

public health. Larger national organizations such as the American Public Health Association

(APHA), the Association of State and Territorial Health Officers (ASTHO) and the National

Association of City and County Health Officials (NACCHO) must appeal to a much broader

public health constituency. This is not to suggest that these organizations are insensitive to

rural concerns, but only that they must be balanced with the overall concerns of the larger

public health community. The National Rural Health Association has been successful at

pushing selected rural public health issues but also has had to balance these concerns with the

other general health care concerns of its constituency, which is made up of health care

providers, administrators, educators, policy experts, and consumers.

The ongoing perception that public health is largely a service for poor people is another

factor, albeit on a more general level. This misunderstanding of the importance and purpose

of public health makes it hard to win the support of the middle and upper class. As a result,

the general public is rarely engaged in the discussion of issues regarding the public health

infrastructure.
The National Advisory Committee on Rural Health, February 2000 8

Additional Resources

! The National Rural Health Association

(NRHA) with funding through a three-year

grant from the WK Kellogg Foundation,

recently launched Rural Community

Leadership Development Initiative. This

initiative aims to create a cadre of rural

leaders to provide key input regarding their

communities real needs. Contact: Robert

Quick, NRHA special assistant to the

executive vice president. Tel: 816-756-3140.

Quick@nrharural.org.

! The Public Health Practice Program Office

(PHPPO) of the Centers for Disease Control

and Prevention (CDC) recently prepared a

free booklet called Principles of

Community Engagement to improve

communication, promote common

understanding and strengthen community

partnerships to fulfill shared public health

goals. Contact: Michael T. Hatcher (Chair),

through http://www.phppo.cdc.gov/

A greater awareness of rural concerns at the Federal and state levels would help to empower

rural public health departments and there are some tools available to make this happen. Since

1991, there has been a state office of rural health within each of the 50 states. These offices

are uniquely positioned to link rural communities to state and federal resources. Funded

through a matching grant program from the Federal Office of Rural Health Policy, most of

these offices are located in the state health departments, but nine are university based. They

are quite variable in scope, staffing and access to resources. One-person offices are not

uncommon. A recent survey of the state offices by ASTHO confirmed that variability. The

survey found that while 41 of the responding states said their state holds a periodic meeting

or conference on public health issues, only 33 said the event included any formal discussion

of rural-specific issues.

Similarly, attention to rural public

health issues at the Federal level is also

variable. While the Federal Office of

Rural Health Policy is positioned to be

the voice of rural health within the

larger U.S. Department of Health and

Human Services, it would be hard

pressed to become the focal point for

rural public health issues on anything

more than a general basis. Currently,

the office has responsibility for

reviewing all Medicare and Medicaid

regulations that affect rural health care

delivery while also administering five

national grant programs. The

fragmentation of public health

programs across different agencies also

makes coordination of efforts and

attention to specific issues such as rural

health a difficult task.

Ultimately, solutions to the leadership void for rural public health will have to come from a

number of sources. One potential model for improving leadership at the state and local level

is the new Management Academy for Public Health, jointly funded by CDC, HRSA and the

WK Kellogg and the Robert Wood Johnson Foundations. The Academya joint effort of the

University of North Carolina School of Public Health and the Kenan-Flagler Business

Schoolwill strengthen the management skills of 600 senior-and mid-level managers in

local and state health departments across Georgia, North Carolina, South Carolina and

Virginia. Participants will come in teams to Chapel Hill, NC for Phase I of the academy, a

one-week intensive management training program covering financial management, civic

entrepreneurship, human resources and strategic management. Managers then graduate to

Phase II, returning home for the next nine months with continuing course study over the

internet, and during two regional seminars. Finally, Academy participants return to Chapel

Hill for Phase III, a wrap-up session. According to program organizers, Academy teams will
The National Advisory Committee on Rural Health, February 2000 9

Empowering Local Communities

The Community Based-Public Health Initiative

(CBPH), funded by the WK Kellogg Foundation in

1991, was one of the earliest efforts to encourage

collaboration between communities, local health

departments and academia to improve public

health. Its specific objectives included building

the capacity of communities to become equal

partners in efforts to improve the community’s

health, enabling teaching, research and service to

be more reflective of diversity and pluralism, and

increasing multicultural competency among

students, faculty, agency personnel and

community members.

produce integrated business plans at the end of their 10-month training to be implemented in

their home agencies to improve service delivery and effective collaboration with others.

Rural communities must be pro-active in seeking participation in such innovative strategies

to link expertise with need, and federal programs should support such rural participation.

Other solutions, undoubtedly, will have to come from rural communities through new and

innovative partnerships. Some communities have already taken the lead. County extension

agents in Georgia are helping communities to empower themselves and strengthen

community infrastructure (Jenkins, 1991). Over the last few years, several rural communities

have shored up their local health systems and staved off potential hospital closures by taking

part in a planning called Community-Initiated Decision Making. This decision-making

method gets local citizens engaged in learning about the importance of the local health care

system on both an economic and a clinical basis, identifying problems and working together

to come up with solutions. The CDC pushes a similar process called the Apex Model, which

is a tool used by the local health department that includes local citizen participation as a key

part of the process. As communities work their way through this process, some rural

advocates are urging communities to consider placing their health departments inside the

local hospital to take advantage of critical

mass and become more of a one-stop shop

for clients. Rural public health

departments could benefit from

developing partnerships with their local

hospitals and taking part in these

community-oriented planning processes.

Some native American tribes have also

taken control of their own public health

decision making, thanks to the Indian

Self-Determination Act. This law allows

tribes to contract for their health care

services through entities other than the

Indian Health Service. In Alaska, for

example, nearly all the health care programs traditionally administered by the Indian Health

Service have been steadily transferred to 13 Alaska Native regional corporations over the

past two decades. Local tribal agencies and officials are becoming increasingly important

decision-makers in the provision of public health services in many rural communities.

Ultimately, the issue of increasing the leadership on rural public health issues has two

distinct challenges. One lies in bringing more awareness of critical rural concerns within the

context of the larger public health debate. The other lies in encouraging the development of

local leaders at the community level who can develop and implement the innovative ideas

needed to ensure the continued viability of the rural public health infrastructure.
The National Advisory Committee on Rural Health, February 2000 10

Training Resources

! The National Laboratory Training Network

has reached over 8,000 individuals through

its seven regional training centers, providing

state of the art public health laboratory

methods. For more info:

http://www.phppo.cdc.gov/about/

! Burke, T, Tran, N, and Shalauta, N. (1995).

Identification of state environmental

services: a profile of the state infrastructure

for environmental health and protection: a

final report. Rockville, MD: Contract No.

240-92-0046.

! The Pew Health Professions Commission, in

its 1995 report entitled Critical Challenges:

Revitalizing the Health Professions for the

Twenty First Century, concluded that the

demand-driven system in health care and

health professions practice will result in

surplus of 100-150,000 physicians in the

next century. However, the same study

concluded that the demand for public

health professionals will increase

substantially.

Workforce Preparedness 

Rural health departments face a

continuing problem attracting

and retaining the proper mix of

public health professionals.

Further, there is a growing need

to improve continuing education

opportunities to deal with new

and emerging threats.

Recruitment, training, placement and

retention of some health professionals

are familiar headaches to rural health

advocates and policy makers. These

difficulties occur within the public

health arena as well, and in fact may

be exacerbated by the greater demand

for, and even more limited pool of

appropriately-trained public health

practitioners. More than four out of

every five public health employees

nationwide – more than 400,000

people – have no degree, certificate or

formal education in public health. The

one exception to this rule may be

nursing. Nurses traditionally receive a

block of instruction in public health in nursing school, but they are only one facet of full

complement of public health employees. That means other members of the local health

department team must learn essential skills on the job. This disparity points out a dramatic

weakness in our public health infrastructure.

It is exacerbated in rural areas that may not be located near the educational institutions that

can help workers get the training they need. Filling other needs in the areas of soil and water

assessment, epidemiology, and food inspection also can be more difficult in some rural areas.

This is in part because of difficulty in paying the salary of these professionals in more remote

areas and also because the volume of work for these professionals may not be enough to

warrant a full-time presence at the local level.

Maintaining the needed diverse skill mix of public health professionals, however, presents

further challenges. As mentioned earlier, local health departments used to be able to depend

on Medicaid dollars raised from providing personal health services to fund some populationbased services, such as assuring clean water supplies and safe-food preparation at restaurants.

As local health departments shift from an emphasis on personal services to more communityfocused efforts, there may be a corresponding loss of Medicaid dollars available to cover

those costs. Because these ‘public health’ services have long been invisible to the general
The National Advisory Committee on Rural Health, February 2000 11

public, their gradual erosion and eventual disappearance in some sites has not yet engendered

public outcry.

The loss of community disease surveillance capacity, lack of oversight over local sanitation,

and inadequate assurance of safe food and water supplies are behind many of the recent,

nationally publicized outbreaks of preventable disease, such as Hepatitis A and E coliinduced food poisoning and new outbreaks of tuberculosis. The growing prevalence of

hepatitis C has put a further burden on public health agencies as the number of people

affected continue to multiply and practitioners struggle with both diagnosing and treating the

disease. Since 1987, the National Academy of Science’s Institute of Medicine (IOM) has

published three reports that identified erosion of the public health infrastructure among the

factors contributing to new and reemerging infectious diseases (Satcher, 1995).

In recognition of these issues, the Centers for Disease Control and Prevention’s (CDC) calls

for increased laboratory-based surveillance, better communication networks and

improvements in the public health infrastructure as cornerstones to combat emerging

microbial threats to health. Attempts to deal with new and emerging threats such as this point

to another critical problem facing rural public health providers: continuing education. The

existing base of rural public health workers will need ongoing training to respond to the new

and emerging public health crises identified by the CDC.

Many rural public health departments may need to recruit new personnel to fill these roles

and to plug gaps in their personnel so they can more adequately address emerging public

health needs. Experts agree that community health needs are too complex to be managed

solely by our individualistic medical care delivery system. Yet incentives to attract a diverse

team to rural areas are even more inadequate than the few incentives available to attract

general clinicians to rural areas. Adapting existing recruitment and retention strategies to

include public health personnel is a potential, relatively painless strategy. One model that

might be particularly appropriate for rural public health providers is the Triple R Network (or

the Rural Recruitment and Retention Network). This recruitment service, which is operated

by the Wisconsin Office of Rural Health, seeks to match physicians interested in rural

practice with rural communities in need of a clinician. The network is made up of 46 statebased organizations such as State Offices of Rural Health, Area Health Education Centers,

(AHECs) and State Primary Care Associations who work together to share and coordinate

information between those seeking physicians and those providers looking for places to

practice.

What is needed right away, though, is a broad-based strategy for improving the skills of the

current public health workforce. Training programs that take advantage of

telecommunication strategies such as internet-based instruction and interactive distance

learning programs are a viable alternative and are discussed in a subsequent section in this

report. Rural communities would also benefit from innovative partnerships with local

community colleges, schools of medicine, nursing and public health. Most land-grant

colleges and universities and other state educational institutions have a service responsibility

to their communities. Rural public health departments would benefit from these resources as

well as any available Federal, state or foundation money that supplements training efforts.
The National Advisory Committee on Rural Health, February 2000 12

Safety Net Vs. Population Services

“The vitality of the public health system has been

undermined in the last two decades by escalating

pressures on state and local governments to

provide medical care for the poor and uninsured.“

1994 statement in JAMA by a group led by officials

from the Centers for Disease Control and

Prevention.

“However necessary, “support for indigent medical

care has exacted a huge toll in lost opportunities

for preventing morbidity and mortality in vulnerable

populations and for promoting optimal health

conditions for the entire community.”

 (Medicine and Health Perspectives, Nov. 23,

1998).

Rural Health Care Safety Net is...

“a complex web of organizations, individuals, and

obligations that depend on the explicit support of

public funds as well as the tacit crosssubsidization of services’...and unlike urban

systems, cannot depend on teaching hospitals

and professional educational programs which

deliver care almost as a byproduct of their training

programs. Rural systems rarely have access to

such resources, and depend more heavily on

publicly subsidized community health centers or

clinics, supplemented by private practitioners,

some of whom receive bonus payments and other

federally-supported incentives to provide unreimbursed care to the poor.”

Ricketts, Slifkin and Silberman, 1998

 Safety-Net Provider Support 

Rural Public Health Providers

have long been a critical part of

the safety net but changes in the

health care market may be

undermining that role.

Public health is one of the key elements

of the safety net that provides care for

the most vulnerable members of the

community. The rural safety net

includes both public and private

professionals and institutions that

provide a disproportionate share of care

to the poor and the uninsured. It also

includes the federal government

through multiple, and longstanding

treaty obligations to tribal governments and their communities.

This traditional role, however, has been under increasing pressure as the public health

community struggles to survive and define itself in an era where cost-effectiveness and the

bottom line in health care delivery are priorities. As a result, the importance of public health

efforts may be minimized and that contributes to the destabilization of the rural public health

infrastructure. The frequently conflicting demands placed upon rural public health

providersto shift from personal to population-based services while simultaneously assuring

the continuity and stability of the safety net—are increasing in a time of scarce resources.

This coincides with the continued ambivalence regarding the appropriate roles and

responsibilities of public health regarding focusing on population-based services or

individual health services.

There appears to be a philosophical

divide within the public health

community. There are those who favor

continuing the role of providing personal

health services for both the indigent and

those enrolled in Medicaid. Others,

though, believe that approach is

inconsistent with recent developments in

the health care system and believe public

health agencies should focus on the

population-based services that serve the

entire community. This conflict has yet

to be addressed effectively at the federal,

state or local level. Different funding

strategies provide competing incentives
The National Advisory Committee on Rural Health, February 2000 13

For More Information On The Rural

Safety Net:

Ricketts, T, Slifkin, R, and Silberman, P. (1998)

The Changing Market, Managed Care and the

Future Viability of Safety Net Providers-Special

Issues for Rural Providers. Background Paper for

the Institute of Medicine. November 11, 1998.

for both roles. What is also clear is that an inadequately prepared and financed public health

infrastructure is increasingly accountable for both types of services, particularly in rural

areas, where private resources that might supplement this mission may be even more scarce

than in urban areas.

Recent transformations in our public health systems with particular implications for the

survival of the safety net are detailed in a recent article in Health Affairs (Hall, 1998).

According to this review, personal health services still consume the largest share of the

average local health department’s staffing and funds, but in most places, that is rapidly

changing. Some health services provided to individuals, such as immunizations, sexually

transmitted disease identification and control, and tuberculosis services, have obvious

positive implications for the community at large because they are targeted at communicable

diseases.

Other personal health services, such as

family planning, mental health services,

and chronic disease monitoring, have

less obvious impact on the community’s

overall health and are likely to be

eliminated first. Comprehensive primary

care services are not commonly

delivered by most health departments,

but in truly remote areas, and historically

in the South, such services have been considered central to the health department mission

because of the shortage of private providers. In such areas, the shift from personal to

population-based services may actually eliminate the safety net for the most vulnerable

members of the community.

The problem facing rural communities is the creation of a possible void in the safety net as

rural public health departments move to population-based services and decrease their

provision of personal health services to the poor. The rural safety net is stretched thinner than

in urban areas, where there are a higher number of large public hospitals, academic medical

centers and Federally qualified health centers that provide outlets for caring for the

uninsured. In rural areas, the safety net is smaller and more intertwined among the few health

care entities that exist, whether it’s a small rural hospital, a private practitioner, a rural health

clinic or the local health department. The loss of safety net services at the health department

will only shift the burden over to the other community providers, which may or may not have

the capacity to handle this new responsibility. Given this transition, there would seem to be a

need for Federal and state support for maintaining the viability of the safety net in these

communities. Direct subsidies to community and migrant health clinics, and indirect

subsidies (via Medicare) to both the private and non-profit sectors to encourage continued

care to the poor will become increasingly essential, as will assuring continued adequate and

appropriate funding for provision of public health services to Native American communities.
The National Advisory Committee on Rural Health, February 2000 14

Additional Resources on Managed

Care and Public Health

! Local Public Health Agencies and Managed

Care Organizations in Rural Areas:

Opportunities and Challenges. (1998) By Ira

Moscovice, Rural Health Research Center,

Institute for Health Services Research,

School of Medicine, University of Minnesota.

Supported by Robert Wood Johnson

Foundation. For more info: Tel: 612-627-

4411. Fax: 612-627-4415.

! Rural Impact of Changes in Public Health,

(1999), report in progress by Rebecca Slifkin

and Pam Silberman, University of North

Carolina, Chapel Hill, funded by Federal

Office of Rural Health Policy. Anticipated

completion Oct 1999. The study will use

several state case studies to answer the

questions: 1) to what extent are rural public

health departments increasing or decreasing

their direct patient services? What factors

are associated with this change?, 2) Have

recent changes in the health care system

affected the ability of local health

departments to fulfill their traditional pubic

health functions?, and 3) In rural areas

where public health departments no longer

offer direct patient care services, has this

function been assumed by private providers,

or has access to services for rural

populations diminished?

Impact of Managed Care 

While managed care penetration

in rural areas remains variable,

the overall impact of managed

care has the potential for

undermining rural public health

systems by altering existing

funding mechanisms.

Managed care is no longer a small

player in either rural communities or

public health discussions. As of May

1997, 57% of rural counties

participated in some form of Medicaid

managed care programs (Slifkin, et al,

1998). The impact of managed care on

the rural public health infrastructure is

closely related to the earlier discussion

of the fragility of the rural safety net.

Insofar as the infrastructure has

responsibility as a provider of last

resort for vulnerable members of the

community, changes in the financing

and delivery of traditional health care

services are important to public health

activities.

Inclusion of all public health agencies

and private providers in managed care

organizational networks is far from

guaranteed, so the potential

development of a fragmented and two-tiered health delivery system must be considered. In

fact, some public health departments and other rural safety net providers may not be able to

enter easily into contracts with managed care organizations due to different cultures and

misunderstandings about their respective roles. If they are unable to reach contract

agreements, public health agencies may find themselves cut out of the funding stream as the

dollars that used to pay for personal health services are now going to the managed care. This

is particularly troubling when the client base and the uninsured continue to seek personal care

services through the public health agency rather than the managed care organization.

The recent ascendance of payers willing only to cover costs associated with insured

individuals within specific plans threatens the cost-shifting that allowed both the provision of

population-based services and the absorption by both private and public safety net providers
The National Advisory Committee on Rural Health, February 2000 15

of uncompensated costs of care to the poor and uninsured. Rural advocates are concerned

about where the funding and coverage decisions of the managed care organizations take

place. While Medicaid managed care has moved into rural areas, the companies providing

these services are often located in urban areas and may have little understanding of the

fragility of the rural safety net and the local health department’s role in that arrangement.

The decisions made about managed care are also part of a larger public debate about the

appropriate role of private sector policies applied to the public provision of health services

(Rice, 1998). The interplay of managed care and public health has been the focus of a

significant amount of recent attention.

A 1999 report from the U.S. Department of Health and Human Services Office of the

Inspector General also focuses on the interplay and dynamics the managed care-public health

relationship. The report indicates that while there is a conceptual alignment between

managed care and public health concepts of prevention-oriented health services, managed

care goals do not translate easily into public health goals. Further, the report points out that

managed care operational decisions and activities are affected by multiple stakeholders, such

as medical providers and private health purchasers, but these groups are often absent in

planning and implementing the collaborations. The issue should garner additional attention

with the Fall, 1999 release of a similar report from the Institute of Medicine. This study

examines the impact of managed care on the safety net. Both of these studies, as well as other

papers and studies point to potential conflicts between maintaining the strength of the public

health in a health care sector that continues to be dominated by managed care.

These studies show that effective collaboration between public health agencies and managed

care organizations in rural areas is likely to require a high degree of negotiation and

communication between parties. Whether that happens remains to be seen. Historically, the

health care system has tended to focus on one-size-fits-all approaches that are usually very

problematic for rural areas. While managed care penetration is increasing in all areas of the

country, delivery systems that are appropriate in urban areas may be inappropriate and

particularly difficult to implement in rural areas (Slifkin, et al, 1998). The 1997 Balanced

Budget Act, which required states to make supplemental payments to FQHCs and RHCs

during a five-year transition period, is another important but temporary form of support.

Clearly, it may be too early to see the full effect of managed care on the public health sector.

What is known at this point is that the move to managed care will bring some dramatic

changes and it is creating some anxiety among public health advocates, state health

departments and other interested parties. A recent qualitative survey of State Office of Rural

Health Directors specifically investigated the public health capacity and infrastructure in

rural areas and confirmed that many policy makers are concerned that managed care may

have a negative impact on rural access to public health services (ASTHO, 1999). Most states

had not yet established any provisions (either legislative or regulatory) to require Medicaid

managed care organizations to contract with local health departments for public health

services. The vast majority of states also do not provide direct funding to local health

departments in rural areas to compensate for the loss of funding through Medicaid managed

care for core public health functions (ASTHO, 1999). Much as federal direction and
The National Advisory Committee on Rural Health, February 2000 16

subsidies helped shape the current organization of existing delivery systems, it may fall to

Federal policy makers to determine the structure and capacity of future public health systems.
The National Advisory Committee on Rural Health, February 2000 17

Creating an Public Health Information

Infrastructure on the Utah Frontier

Until recently, the rural and frontier county health

departments of Southern Utah were isolated by

more than just distance. With few computers or

telecommunications resources, county health

officials had no way to take advantage of new

communication technologies that would link them

to the State health department in Salt Lake City.

Now, the Utah State Department of Health is

using telecommunications to reach out to its most

remote offices in the southern part of the state to

create the Utah Public Health Information

Network.

The network has put e-mail, document transfer,

and Internet access within reach of its most

isolated branches. Now, these offices can share

and access information such as state

immunization records or information on Medicaid

eligibility rules and other regulations pending at

both the state and federal level. The project also

provided training for state health workers so they

could take advantage of the new technology.

Some offices are also working on developing

electronic surveillance tracking.

Telecommunications 

Many rural communities that are

most in need of recent advances

in the field of

telecommunications technology

may be least equipped to take

advantage of it.

The telecommunications revolution has

had significant implications for health

care providers as a way to bridge the

gap of time, distance, and isolation.

Much of the attention to date has

focused on the clinical applications

under the catch-all term,

“Telemedicine,” with an emphasis on

the remote delivery of clinical care. For

many public health care providers,

however, the term telehealth more

effectively encompasses the full range

of health care uses for this technology.

Many public health advocates are

already taking advantage of

videoconferencing and regional

“continuing Education” activities that

support professional development for

isolated staff. This technology has the potential for effectively supporting recruitment and inhouse retention of competent personnel in local health departments.

Telehealth can also bring the expertise of essential public health professionals to rural areas

on an “as needed basis,” making the use of such specialized knowledge economically

feasible for communities whose need for such services may be both sporadic and immediate.

Dealing with the outbreak of the Hanta virus and crafting an effective local emergency

response to the derailments of trains carrying toxic wastes are just two examples of situations

where telehealth can help make a modest infrastructure sufficient. In fact, in the wake of

recent concerns regarding the public health implications for biological terrorism, telehealth

becomes an essential component of local “first response” capabilities. The ever increasing

base of medical knowledge coincident with the increasing global mobility of our population

makes the rapid deployment of new clinical guidelines and standards of practice critical both

to maintaining the competence of isolated professionals and the safety of the public. Of

particular note is CDC’s new bioterrorism budget initiative, which received approximately

$121 million in fiscal year 1999 and has a strong telecommunications component. Some of

the grant funds will be used to create Health Alert Networks (HANs) to work towards

creating a nationwide system to provide information, electronic linkages, and resources for

improving organizational competence and capacity when responding to bioterrorist acts.
The National Advisory Committee on Rural Health, February 2000 18

Rural health departments may have to deal for the first time with malaria and/or resistant TB

in recent immigrants while also being prepared for routine immunizations. The ability to

share new knowledge and quickly train workers through distance learning may be a critical

need for local health departments. Telehealth technology may provide a useful tool for

accomplishing this goal by linking local public health workers with the expertise of

universities, schools of public health, the state health department and the CDC a smoother

diffusion of innovations in practice. For example, telecommunications allowed the fairly

easy recent distribution of new federal guidelines on management of Hepatitis C to public

health agencies with the capability to participate in such networks of knowledge exchange.

The emerging field of public health informatics is yet another use of this versatile tool. Data

transfer is particularly important when trying to understand and manage the health of

populations rather than individuals. Telehealth also has the potential for stretching scarce

resources. Small rural public health departments that may not have enough resources to hire a

full-time epidemiologist can use a telecommunications link to the state health department to

get these services on an as-needed basis.

While the potential of telehealth is readily apparent, the reality of applying this technology is

still developing. The development of clinical telemedicine systems has been driven by

regional medical centers in search of referrals. No such interest has yet materialized to

support development of public health networks. In fact, the isolated rural areas that may

benefit the most from this technology often lack the infrastructure needed to take advantage

of it. Consider these numbers:

! Less than half of the state and local public health agencies have adequate

communications and information systems.

! One recent Hawaiian study indicated that although 85% of rural health workers had

access to computers, only a small minority (30%) had modems, and even fewer used

online resources, or could access the free electronic databases at public and university

libraries (Lundeen, Tenopir and

Wermager, 1994)

The unreliability or absence of even

the most basic communication

systems in many remote areas of the

country reinforces the notion that

stabilizing the public health

infrastructure with

telecommunications must start at a

very basic level. Even seemingly

simple tools such as personal

computers and modems can

dramatically improve public health

capabilities at the local level.

A Resource for Public Health

The Public Health Training Network (PHTN) is a

distance learning system that takes training to the

learner. PHTN uses a variety of instructional

media ranging from print-based to videotape and

multimedia to meet the training needs of the

public health workforce. Since 1993, PHTN has

successfully trained over 300,000 public health

professionals. Key to its effectiveness is the

pivotal role played by 50 State Distance Learning

Coordinators who ensure state and local health

workers are able to access PHTN programs. For

more info: http://www.cdc.gov/phtn/.
The National Advisory Committee on Rural Health, February 2000 19

Improving Communication

In September, 1997, the American Public Health

Association (APHA) held a workshop on

“Effective Communication of Public Health Data

and Information: Skills for a Changing Public

Health Environment.” The workshop was a

collaborative effort among APHA, the University

of Pittsburgh Graduate School of Public Health,

the Association of Schools of Public Health and

the Pennsylvania Public Health Association, and

was supported by APHA’s Public Health

Innovations Project, a cooperative agreement

funded by CDC.

Public health advocates and

policymakers alike see

telecommunications as one of the key

tools for reinforcing the public health

infrastructure. They point to the need to

link local public health agencies with

state health departments for data

collection and evaluation and to provide

core public health training to areas. Such

links are not without problems, though.

There are concerns about costs of this

technology. The rapid expansion of

technology makes equipment purchasing difficult since much of the off-the-shelf computer

equipment for this technology quickly becomes obsolete. Further, the high

telecommunication costs of linking rural health departments to urban partners can also be

prohibitively expensive. Consequently, some public health departments have relied on state

and Federal support to offset some of the fixed costs. Across the country, states have built

telecommunication networks that can help support these activities. Federal agencies such as

the Health Resources and Services Administration (HRSA), the Centers for Disease Control

(CDC), the National Library of Medicine (NLM), the Department of Commerce and the

Department of Agriculture have provided millions of dollars in grant funds for telehealth

projects that included public health functions.

The Office for the Advancement of Telehealth (OAT) in HRSA, which has funded telehealth

network projects since 1994, has found that its most successful projects are those that

incorporate a range of uses on their

network system. This often results in

systems that serve a variety of functions

from specific clinical applications such as

specialty consultations to more public

health oriented activities such as distance

education and health information sharing.

While the early results are promising,

telehealth technology will not be a

panacea for the rural public health

infrastructure. Rather, most advocates

point to it as another tool that can be used

to target specific education and

information-sharing needs.

Improving the Practice of Public

Health

The Information Network for Public Health

Officials (INPHO) was initiated by CDC in 1992

as part of its strategy to improve information

exchange and thus strengthen the public health

infrastructure. Twenty one states currently

participate in this effort to make public health

practice more effective. For more info:

http://www.phppo.cdc.gov/inpho/
The National Advisory Committee on Rural Health, February 2000 20

Unexpected Cases Cut Deep

The Pamlico (N.C.) County Health Department

has treated 28 people for rabies in the past two

years and it can ill afford any more.

As state and federal public health block grants

have been cut in recent years, there's precious

little money left over to handle unforeseen

emergencies. But in rural areas like this coastal

county of North Carolina, rabies outbreaks do

happen and it's the local public health agency that

has to handle it. "An average eight-year old child,

it costs me $800 to treat that child," says Jenny

Lassiter, the Pamlico County Health Director. "The

state Medicaid reimburses me $400."

During the first rabies outbreak in 1998, Lassiter's

agency spent $7,000 on vaccines and treatment.

While two of the 11 people treated qualified for a

state indigent care rabies program, the rest were

listed as self-pay. So far, the health department

has collected $1,200 of its fees. The local

residents in this poor, underserved community

don't have the money. And there's little flexibility in

either the Federal or state funding to cover these

costs. That means Lassiter must pull dollars from

somewhere else to cover the shortfall.

"It's coming out of your pocket either way,"

Lassiter said, "and I do not have a good answer

other than the fact that there has got to be some

kind of block grant money that has to be

established to address local issues and

problems."

Funding Issues 

The fragmented layers of

Federal, state and local funding

of public health activities creates

a confusing financial patchwork.

These funding lines often have

conflicting guidelines and lack

the flexibility to respond to

community public health needs

One of the underlying reasons for the

current instability across the public

health landscape lies with the complex

and ever-shifting funding sources for

these services. Part of this equation, the

impact of managed care, has already

been discussed. The other public health

funding streams, however, are just as

variable since most public health

agencies are funded by a patchwork of

Federal, state and local sources. Much

of the money starts at the Federal level

before being sent to the states in the

form of large block grants. The

Women, Infants and Children (WIC)

nutrition program and other USDA

nutrition funds account for the largest

share of state health departments’

budgets while the Maternal and Child

Health block grant (Title V) is a distant

second. Other federal public health

grants include family planning (Title X) and the preventive services block grant (Wall,

1998).

How those dollars break down often depends on how public health is defined and the extent

to which it varies state to state. For example, according to Public Health Foundation

estimates, in FY 1995, expenditures by state health agencies totaled $13.2 billion. Of that

amount, approximately 66.8% funded direct delivery of medical and related services (e.g.

primary care and health promotion). The remaining 33.2% was used as follows:

! 15.8% for environmental health, health resources and regulation, technical and support

services, vital records and health statistics (e.g., licensing, inspection, quality assurance,

public health engineering, EMS development).

! 12.2% for the operation and regulation of state hospitals, residential facilities, home

health and skilled nursing agencies.
The National Advisory Committee on Rural Health, February 2000 21

The Association of Schools of Public Health

supports the following FY2000 funding

recommendations for programs of primary

concern to the public health community:

Centers for Disease Control and Prevention

! Prevention Centers: $30 million

! Prevention Research: $100 million

! NIOSH Training: $20 million

! Environmental Research $8 million

! Injury Control: $20 million

! NCHS: $110 million

Health Resources and Services Administration

! Public Health, Preventive Medicine, Dental

Public Health: $ 20 million

! MCH Training: $ 20 million

! Health Professions: $316 million

! MCH Block Grant: $800 million

! HRSA Program Mgmt $136 million

! 2.7% for operation of public laboratories and services (medical examiner) and

regulation of others.

! 2.5% for “general support of local health departments.”

Since federal dollars, usually in the form of block or categorical grants, still make up a

substantial portion of most states’ public health budgets (50-85%), these programs are key

determinants of the fiscal capacity of the public health infrastructure. Often, those dollars

come with strings attached. That means the availability of federal dollars often dictates the

activities of state public health agencies. For example, Texas and Colorado support few

public health programs that do not draw federal dollars. Likewise, state support of public

health dollars differs with each state.

Local funding for public health

agencies, particularly rural public

health agencies, is often dependent on

local tax revenues

This confusing patchwork of existing

financial mechanisms often exacerbates

the instability and inefficiency of the

rural public health infrastructure. One

local health director interviewed by the

National Advisory Committee on Rural

Health for this report indicated that he

routinely managed more than eighty

distinct funding streams in the course

of his annual work. The associated red

tape and complexity of these funding

streams have prompted some rural

public health advocates to favor more

streamlined and flexible funding mechanisms. Yet alternatives provided to date have not

always exceeded, or even met the achievements of the older, categorical funding streams.

Both block and categorical funding mechanisms often lack the flexibility needed to respond

appropriately to local emergencies. Health officials frequently describe the frustration of

having minimal or no “untargeted” funds to address even well-recognized, or predictable

local needs, which do not fall into simple budget categories.

The devolution of responsibility for social and health services from the federal to the state

governments has dominated almost two decades of public policy. In such traditional public

health programs as Maternal Child Health, such transfer of power has also been accompanied

by the significant growth of block grants and a decrease in traditional categorical funding

streams. The Maternal and Child Health Services Block Grant (MCHSBG), passed in 1981,

provides direct health services to women, infants, children and youth, and consolidated eight

categorical programs into a single, reduced federal block grant to the states.

The Block Grant formula (which considers both number of low income individuals and poor

health indicators) theoretically targets resources to needy populations in both rural and urban
The National Advisory Committee on Rural Health, February 2000 22

areas. But the formulas (last reviewed in 1982) have been outdated for years, and may no

longer reflect true demographics.

The devolution of federal power to the states may have had additional negative impacts upon

the efficacy of this and other block grants. First, power and funds shifted to state legislatures

that may have little institutional memory, particularly for those funds previously

administered at the federal level. Second, some state legislatures might be less likely than

their federal counterparts to contain strong public health or rural advocates.

Rural populations served by multiple agencies (local, county, state, federal, including tribal

and military) create an even more complicated funding picture. In the absence of concerted

coordination efforts, some rural populations may be ‘over-served’ and others virtually

ignored. Some public health advocates have called on the Federal government to take the

lead in rewarding inter-agency collaboration in its distribution of federal funds and providing

technical resources to facilitate such essential coordination.
The National Advisory Committee on Rural Health, February 2000 23

Conclusions 

The instability of the rural public health infrastructure presents a daunting challenge for rural

health advocates, policymakers, elected officials and public health workers. While much

work remains to be done, it is important to understand that there is also an opportunity for

positive change. Despite current problems, however, it is worth noting there has been

dramatic improvement in public health in the past 100 years. In observance of National

Public Health Week 1999, the Centers for Disease Control and Prevention identified “Ten

Great Public Health Achievements in the 20th Century,” which are listed below:

! Vaccination

! Motor vehicle safety

! Safer workplaces

! Control of infectious diseases

! Decline in deaths from coronary heart disease and stroke

! Safer and healthier foods

! Healthier mothers and babies

! Family planning

! Fluoridation of drinking water, and

! Recognition of tobacco use as a health hazard

None of these achievements would have been possible without a capable public health

infrastructure and several of them have not yet fully reached rural communities. The next set

of improvements may prove a more daunting challenge, especially for rural areas.

This report has briefly identified and reviewed six salient threats to the rural public health

infrastructure: leadership, workforce preparedness, safety-net provider support, the impact of

managed care, telecommunications and funding. It has also tried to identify resources and

emerging “best practices” that may be of benefit to rural communities and to identify federal

options to help stabilize the rural public health infrastructure. The challenge comes in

deciding where the most pressing problems are and what are the best ways to bring about

needed change.
The National Advisory Committee on Rural Health, February 2000 24

Recommendations 

At the close of its September 1999 meeting, the Committee sent two public health

recommendations to Donna Shalala, the Secretary of the U.S. Department of Health and

Human Services. They are listed on the following pages:
The National Advisory Committee on Rural Health, February 2000 25

NACRH-10/01/99

NATIONAL ADVISORY COMMITTEE ON RURAL HEALTH

FISCAL YEAR 2000 RECOMMENDATION

Recommendation Title: Improved Coordination of Federal Public Health Activities

Current Law: (Not applicable, falls within the Secretary’s authority)

Proposal: The National Advisory Committee urges the Secretary to seek an Executive Order

for the creation of a Federal Interagency Public Health Coordination Committee comprised

of senior representatives from the various public health agencies and federal departments.

The committee would produce an annual report (the first of which would be produced within

12 months of the establishment of the Committee). The Committee would study current

efforts by each of the Federal Agencies involved in public health activities overall while

evaluating ways to integrate funding streams to benefit rural communities in the areas of

leadership development, workforce development, viability of the safety net, impact of

managed care, and telecommunications. This committee would include appointed

representatives from the Department of Health and Human Services, the Department of

Agriculture, the Environmental Protection Agency, the Department of Commerce, the

Department of Veteran Affairs, the Department of Labor, the Department of Education, the

Department of Housing and Urban Development, the Department of Transportation, the

Department of Defense and any other relevant Federal agencies.

Rationale: Currently, public health funding is spread across several Federal agencies with

little or no coordination of how these dollars are targeted. The result is a patchwork of

Federal programs that leads to confusion and conflicting intents at the State and local level.

Creation of a Federal inter-agency coordinating committee could go a long way toward

helping improve interaction among these agencies and the subsequent use of these funds at

the local level. Ensuring coordination at the Federal level will only serve to improve

implementation of public health efforts at the community level. This initiative would prevent

parallel and disconnected activities by different agencies and programs while improving

evaluation of Federal public health efforts. The further attention to rural public health issues

would recognize the fact that the majority of local health departments are small entities

located in rural areas.

This committee would build upon the efforts of the Public Health Function Steering

Committee within the Department of Health and Human Services. By expanding to all of the

cabinet-level agencies, this committee would better ensure coordination of federal public

health efforts, particularly as they relate to rural areas. Furthermore, this coordinating

committee could serve as a powerful force for change and improvement at crucial time in the

evolution of the public health system. Recent changes in the health care system, the impact of

managed care and continued devolution of Federal responsibility to the states have created a

great deal of uncertainty over the goals and mission of public health activities. This initiative

could help provide needed guidance to public health activities and create a framework for
The National Advisory Committee on Rural Health, February 2000 26

addressing these challenges. Improved coordination of Federal public health activities could

help avoid programmatic duplication and improve efforts at strategic planning related to

public health. This, in turn, would provide assistance to agencies as they comply with the

Government Performance Results Act (GPRA).

Effect on Population: Better coordination of Federal public health activities would improve

delivery of public health services nationwide.

Cost: (in millions) To be determined by the Secretary

FY 2000 FY 2001 FY 2002 FY 2003 FY 2004

Effective Date: To Be Determined
The National Advisory Committee on Rural Health, February 2000 27

NACRH-10/01/99

NATIONAL ADVISORY COMMITTEE ON RURAL HEALTH

FISCAL YEAR 2000 RECOMMENDATION

Recommendation Title: Creation of a Dedicated Funding Stream for Public Health Activities

Current Law: Public Health Service Act (42CFR)

Proposal: The Committee urges the Secretary to support the development of a dedicated

funding stream for public health infrastructure activities with assurances that funding is

equitably distributed among rural and urban health departments at the local level.

Rationale: One of the underlying reasons for the current instability across the public health

landscape lies with the complex and ever-shifting funding sources for these services and the

rigid nature of the funding requirements. Since federal dollars, usually in the form of block or

categorical grants, still make up a substantial portion of most states’ public health budgets

(50-85%), these programs are key determinants of the fiscal capacity of the public health

infrastructure. Often, those dollars come with strings attached. That means the availability of

federal dollars often dictates the activities of state public health agencies and their local

health departments. That leaves public health departments with no funding source to help

them adapt to the myriad changes now taking place. Public health departments face

immediate challenges in a number of areas. The growing influence of managed care has had

a significant impact on public health funding and upon the health care safety net. Studies also

indicate that less than half of the nation’s public health workforce has had training in public

health. The expansion of telecommunications technologies holds great promise for use in the

field of public health both in sharing data and information but also for increasing training

opportunities. Unfortunately, local health departments have been unable to take advantage of

these new technologies. These issues and others directly affect the continued viability of

public health. Federal categorical and programmatic funding has not kept pace. Public health

departments do not have a direct funding line for responding to the changing environment in

their respective states and communities. Creation of a dedicated and flexible funding stream

for public health would improve quality, stability, and accessibility of public local health

resources. Further, ensuring an equitable distribution between rural and urban health

departments would ensure that the needed funding gets to the local level.

Effect on Rural Residents: The provision would ensure that a dedicated funding source

would be available to address key issues related to the support of the rural public health

infrastructure that is not tied to categorical constraints.

Cost: (in millions): To be determined by the Secretary

FY 2000 FY 2001 FY 2002 FY 2003 FY 2004

Effective Date: Upon implementation
The National Advisory Committee on Rural Health, February 2000 28

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