The document discusses tensions around the role of local health departments in providing direct personal health services to communities. There is debate around whether health departments should focus on preventive care for whole populations or provide treatment services to individuals. Due to budget cuts, health department services that target low-income communities are often underfunded. Meanwhile, hospital sectors receive most health care funding despite concerns about the rising costs of hospital-based care and their focus on acute needs rather than prevention.
The document discusses tensions around the role of local health departments in providing direct personal health services to communities. There is debate around whether health departments should focus on preventive care for whole populations or provide treatment services to individuals. Due to budget cuts, health department services that target low-income communities are often underfunded. Meanwhile, hospital sectors receive most health care funding despite concerns about the rising costs of hospital-based care and their focus on acute needs rather than prevention.
The document discusses tensions around the role of local health departments in providing direct personal health services to communities. There is debate around whether health departments should focus on preventive care for whole populations or provide treatment services to individuals. Due to budget cuts, health department services that target low-income communities are often underfunded. Meanwhile, hospital sectors receive most health care funding despite concerns about the rising costs of hospital-based care and their focus on acute needs rather than prevention.
With the onset of the fiscal crisis, such services have again come under attack. A key element in Slince the beginning of the New York City fis- the conflict is that, since health department ser- cal crisis in 1974, the City's Department of Health vices are targeted for poor people, they are often (DOH) has undergone drastic reductions in its "poor programs"-that is, they receive only mar- budget that have severely affected its levels of ser- ginal support in the best of times. In 1974, less vices and personnel. In order to understand the than five percent of the $41.7 billion of tax full impact of these cuts, however, it is necessary money expended for health services in the U.S. to see them against a backdrop of long standing was allocated to health departments. As a result, tensions which have marked the Department's health department programs are often the "last history. funded" and the "first de-funded." The basic question underlying many of these On the other hand, most of today's health care tensions concerns the definition of the proper dollar is allocated to the hospital sector. This in- role of a local health department. To this day, cludes a growing role for hospital-based pre- around the country, this question remains a ventive and primary ambulatory care. There are, source of real debate. however, serious questions about the appropriate- According to a recent report, one quarter of ness of the hospital as a base for such services. all reporting local health departments today render Hospitals, in general, are not oriented toward "personal health services" (that is, treatments preventive care or health promotion, but to to individual patients) and this proportion has acute care; their orientation is often to diseases, grown steadily in this century. Such services not whole people; to individual cures rather than may take the form of well-person care only (child community problems; and to keeping beds full of health exams, immunizations, PAP smears), or people, not keeping people out of beds. well-person and sick-person care provided to spe- It has also become increasingly clear that cific categories of the population (child health or basing services in hospitals is likely to increase geriatric care), or care for a particular problem (tu- overall costs. Hospital costs in particular have berculosis). In some cities, the provision of per- driven health costs skyward in recent years. sonal health services extends to the provision of Moreover, it is not clear that hospitals have the comprehensive ambulatory care-both routine capacity to handle increased ambulatory ser- acute care (primary care) and preventive services. vices. Last year in New York City, over a million (Newark, Boston, part of Atlanta, Denver, and and a half people used DOH clinics. It is ques- Detroit all have some form of comprehensive am- tionable whether hospitals, whose outpatient de- bulatory care system run by their city or county partments and emergency rooms are already over- health departments). crowded, could handle such an increased load. In some localities, health departments are the Health departments are unique among Ameri- only providers of such services as family planning, can health providers. Their epidemiologic orienta- maternal and child care, home care, school health tion and statutory mandates to cover whole and chronic disease programs. In many localities, communities put them in a unique position to health departments are the only providers of monitor not only the quality of services deliv- free personal services for poor people. In 1975, ered, but also the appropriateness of the mix. such services accounted to 72 percent of all Hospitals, in contrast, tend to monitor only the expenditures (or $2 billion annually) by state needs of those that use them, rather than the health agencies (1). needs of the community as a whole. The New York City DOH has historically been According to Dean Myron Wegman, "It might at the forefront of providing these direct personal be well to build on the principle used in record health services. But the progress in offering them keeping in many Child Health Stations, of tab- has not been linear. Throughout its long and dis- ulating not only the immunizations performed, tinguished history, the expansion of DOH func- but rather the number of eligible children whose tions to include direct personal services has been immunization status is not satisfactory. The idea a source of tension and controversy concerning of measuring tasks undone instead of counting 7