Healthcare Reform ≠ Public Health Reform: On Pathogens, Poverty, and Prevention

Few would deny the contentiousness of the ongoing healthcare reform debate in the United States. Referencing the Patient Protection and Affordable Care Act (P.L. 111–148), a recent article in Foreign Affairs noted that ‘‘no U.S. law has been more passionately opposed by Republicans.’’ Unsuccessful efforts to replace or repeal the Act keep coming, proposed and then voted down or withdrawn during both the Obama and Trump administrations. We all have witnessed this drama play out in Washington for nearly a decade by now. Yet a mistaken notion persists, seen in news stories and op-ed pieces from both sides of the political aisle, that this has been a national debate about public health and the reform of the institutional public health system in the United States. As has been noted elsewhere, no such debate has occurred. The recent legislation, moreover, ‘‘does not take a public health approach to addressing deficiencies in the United States health system or challenge the decades-long medicalization of health with a population-based approach’’ (p. 341). This misunderstanding is rooted in widespread misunderstanding of what public health is, especially in an underappreciation that invoking the phrase ‘‘public health’’ connotes something quite distinct from ‘‘healthcare’’ or ‘‘medicine.’’ The latest edition of the authoritative A Dictionary of Epidemiology defines public health as the ‘‘specific policies, services, programs and other essential efforts agreed (ideally, and often, democratically), organized, structured, financed, monitored, and evaluated by society to collectively protect, promote, and restore the people’s health and its determinants’’ (p. 230). This includes the work of ‘‘institutions, public and private organizations,’’ and ‘‘scientific disciplines and professions’’ all of whom labor to ‘‘prevent disease and disability, prolong life, and promote health through the organized and collective efforts of society.’’ So while healthcare is a component of the public health enterprise, it is only one aspect of a multifactorial effort aimed at supporting the health of individuals and the public at large. A special emphasis of such efforts, as indicated by the mission of the Commissioned Corps of the U.S. Public Health Service, is supporting efforts directed ‘‘to underserved and vulnerable populations.’’ These main points define the mission of the public health sector.