An Antipoverty Agenda for Public Health: Background and Recommendations.

The debate on health care reform in the United States, which culminated in the passage of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act and the signing of associated public laws in 2010, initiated a national discussion that is ongoing. Critiques and countercritiques of this legislation are ever present across the political spectrum. Because the new administration has broached the possibility of repeal and replacement, the discussion shows no sign of abating. This debate is often misrepresented as being about public health reform; however, although the legislation has important public health implications—notably, provision of insurance coverage to uninsured Americans—it was not explicitly written as a public health law, and its public health impact may be dampened by not having addressed social-structural determinants of population-health disparities. Indeed, it may be a stretch to refer to this national discussion as a debate on health care reform; medical care expenditure reimbursement reform may be more accurate. The subject matter centers on medical care—its organization, delivery, and financing— with scant attention paid to the mission of the public health sector. What would true public health reform look like? First, it would focus on determinants of population-health disparities, especially those that are rooted in inequities and injustices resulting from social structure and policy. This perspective is consistent with the primary-preventive, communitarian, and social-justice orientations of public health. Second, it would prioritize factors responsible for the greatest morbidity, mortality, and underutilization of preventive care. Of the causes of widespread and enduring populationhealth disparities, social conditions, especially poverty, are the most fundamental. The social, economic, political, and environmental dimensions and sequelae of inadequate material resources are acknowledged as among the greatest contributors to the ill health of populations, in the United States and globally, by the Centers for Disease Control and Prevention, National Institutes of Health, World Health Organization, and US Public Health Service. Accordingly, a renewed emphasis on antipoverty efforts is advocated here as a focal point of a national public health agenda. Background