The Rostrum By H. H. ROHRER, M.D., M.P.H.

Public health: government's stepchild

SEVENTEEN years as a participant in and observer of public health activities in the state of Illinois have taught me that public health, at both local and state levels, is a governmental stepchild. Since elected officials do not understand public health, they perennially underfund it, leaving it to survive without resources, like some modern-day Hansel and Gretel.

Why is this the case? Several reasons immediately come to mind: 1) The results of public health activities frequently are not readily apparent because public health improvements are usually slow and long-range; they are neither spectacular nor glamorous. 2) Public health agencies do not have a politically important constituency. Many of their clients are either young, old, poor, uneducated or otherwise disenfranchised people. They are not the ones who call or write their county board members or their state legislators. 3) It is hard to prove the success of public health efforts because success can often be measured only by what does not happen, e.g., communicable disease outbreaks that do not occur or elderly people not admitted to nursing homes at public expense because they have received adequate health care, support and education at home.

Public health practitioners have not been successful in getting elected officials, or the public in general, to understand that the major increases in longevity and living standards are due not to breakthroughs in treatment of acute medical and surgical conditions but rather to the widespread practice of public health measures — pasteurization of milk, chlorination of water, sanitary disposal of sewage, refrigeration, immunizations, improved maternal and infant care, improved housing and better nutrition. Of the 30-plus year increase in the average life span since 1900, probably no more than six years are attributable to breakthroughs in acute medical care technology. At no level of government is it widely understood that $1 spent on public health is worth $100 spent on acute care. Public health has never had much "sex appeal," and it probably never will.

Here, briefly, are some examples of the low priority given to adequate funding of local health departments in Illinois:

1. Abolishment of the Individual Personal Property Tax. In 1970, when the new Constitution was adopted and the state income tax introduced, the tax on individual personal property was abolished. This personal property tax represented a significant source of revenue for health departments created by public referendum. Provisions were made to replace lost revenues for other taxing bodies through use of sales tax or income tax, but not for public health. We simply lost that portion of our tax base.

2. Replacement of the Corporate Personal Property Tax. The new Constitution also instructed the legislature to abolish the corporate personal property tax in 1979 and to replace it with another. When the legislature finally replaced it, I believe it was the legislative intent that all taxing units benefiting from the old tax should benefit in an equal proportion from the new. In fact, that has not happened. Many county boards have not replaced tax money lost to health departments; instead, revenue from the replacement taxes has been reallocated, generally away from referendum health departments to the county general fund.

3. History of Grants to Local Health Departments. Although the Illinois Department of Public Health mandates that certified public health departments provide 10 basic programs, the state has never provided much support from the general revenue to assist, in contrast to the subsidies provided to mental health and other agencies. In fact, grants to local health departments as a percentage of Illinois state general revenue fund monies have fallen from a paltry .089 percent in 1965 loan even more paltry .061 percent in 1982, and is now only 47 cents per capita.

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Despite the obstacles, much has been achieved both programmatically and organizationally in the past 17 years including the following:

• There are now 67 local health departments compared to 33 in 1965.
• Types of public health programs have greatly expanded.
• There has been a significant real increase in public health dollars spent at the local level, basically because of the ingenuity of local health departments.
• There is now enabling legislation to merge public health and tuberculosis control activities and greatly strengthen generalized public health programs, especially in unserved or underserved counties.
• Referendum health departments can now levy 10 cents per $100 assessed valuation versus 5 cents in 1965.
• Public health agencies are permitted by law to charge fees for service.
• Public health workers are much more astute and active politically than they were in 1965.
• The advent of Medicare and Medicaid has made prevention and support services available to many previously unserved.
• The Women, Infants and children food program is helping to reduce the number of nutritionally impaired mothers, babies and infants.
• Polio is practically unheard of; measles is a rarity; rubella is under control.
• There is an improved spirit of cooperation between state and local public health agencies.
• The spirit of prevention is sweeping the land. While it is not yet reflected in dollars saved, it is an important attitudinal change that bodes well for the future.

The future of public health, at least in the near term, is going to be difficult because of the paucity of funds at all levels of government. Block grant reductions will affect few local health departments because they received little or no block grant money in the past. Taxpayer groups will continue to be active in Illinois, and public health departments must be ready and willing to justify their programs with facts and figures. The press for deregulation will continue. Health department regulations must be carefully reviewed to determine if they can truly be justified in their present form.

With all of these challenges come opportunities. First, we have a new opportunity to market public health services as the dollars grow scarcer and the costs of acute medical care continue to escalate. Second, public health departments have a unique opportunity to carefully look at their organizations and the services they provide. Any organization that has too much money, be it public or private, has a tendency to become fat and sloppy. In the private sector there was little or no concern for the increase in wages and benefits of employees or the horrendous escalation of health insurance costs so long as the manufacturers could charge more for their products and sell them. Public agencies were no better. So long as the tax dollars flowed in, they could continue to provide the same old services without a serious thought about their cost or value. No more! Public health agencies can now seize the opportunity of austerity to remodel their organizations and services. Third, fees as a source of revenue, except for Medicare and Medicaid, are largely untapped in most health departments in this state.

In the last analysis, new administrative arrangements must be formed at the local level, so the existing county health departments are strengthened and expanded to serve adjacent counties. Administrative costs per person served would be reduced; programs would be strengthened; and the public's health, both physical and fiscal, would be improved.

H. H. Rohrer, M.D., M.P.H., is director of health, Peoria City/County Health Department, and president of the Illinois Public Health Association.

November 1982 | Illinois Issues | 39