Stem cell research is still a current health care issue. The United States Food and Drug Administration (FDA) has only approved a very limited number of treatments to date, yet stem cell research and treatments are practiced freely in the United States. Discuss two or more ethical consideration either for or against the use of stem cells in treatment. Provide supporting references for your position.
STATEMENT ON THE INTEGRATION
OF FAITH AND WORK
A
s a university, we believe that the message of Jesus Christ
bears profound implications, not only for individuals, but
also for society and the ways that we as individuals live
within it. The Lord Jesus instructed His followers to live
as salt and light within society, which implies a call to live out our lives
in ways that contribute to the common good. We are convinced that
this call extends to the workplace and that our respective vocations
represent vital opportunities to glorify God by serving others in ways
that promote human flourishing. Therefore, by God’s grace, we seek to
distinguish ourselves as a university by instilling a sense of vocational
calling and purpose in our students, faculty and staff in accord with
the following principles:
WE BELIEVE that God’s Word speaks authoritatively about creation,
fall and redemption as well as the restoration of all things through
Christ Jesus. Therefore, we are convinced that the Christian
worldview offers hope of restoration, not only for individuals, but
also for families, communities and societies in which individuals live,
work and serve one another.
WE BELIEVE that God the Almighty created the world, placed
human beings within it and blessed them by making them responsible
for cultivating and caring for creation. Therefore, we are assured that
our work within the world matters to God and our neighbors, and
that we honor God by serving others in ways that promote human
flourishing.
WE BELIEVE that Jesus Christ is both Savior and Lord and that all
who follow Jesus should seek His Kingdom and His righteousness
in relation to all aspects of human experience, including culture
and society. Therefore, we have resolved to carry out our work
within the public arena with compassion, justice and concern for
the common good.
WE BELIEVE that Jesus’ death, burial and resurrection secured
abundant and eternal life for all who believe and that Christ
transforms all that we say and do. Therefore, we are convinced that
Grand Canyon University should positively impact those who study
at, work for and live near the university in ways that accord with the
teachings of Jesus Christ.
WE BELIEVE that mankind was originally created in the image of
God and given responsibility over creation, but that all have failed to
fulfill their God-given purpose and responsibility. We believe that God
redeems and restores men and women in Christ, creating them anew
for the good works He has prepared them to do. Therefore, we are
confident that the work we do is a part of God’s calling on our lives
and a means by which we can glorify God as we meet others’ needs.
WE BELIEVE that regeneration by the Holy Spirit is essential for
salvation and that the work of God’s Spirit in the human heart
invariably results in renewed purpose and the growth of Christ-like
love for neighbors and neighborhoods. Therefore, we are certain that
God is working to restore the broken lives and communities of this
fallen world through the collective gifts, talents, skills and resources of
those who have been transformed by the power of the gospel.
WE BELIEVE that salvation comes through Jesus Christ alone and
involves redemption of the whole person. Therefore, we are convinced
that the Christian life must involve compassion and care, not only for
the spiritual needs of mankind, but also for basic physical needs that
stem from poverty, oppression and injustice.
WE BELIEVE in the spiritual unity of all believers in Christ and that
evangelism and societal engagement are duties of the Christian life.
Therefore, we are devoted to demonstrating the love of Jesus together
as we share the gospel message and shape society according to the
principles of His Kingdom.
WE BELIEVE that the gospel message denounces evil and injustice
while offering hope for reconciliation to Christ and the restoration
of human culture and society through Him. Therefore, we recognize
and embrace the potential of human work for furthering the greater
good and strive to further the good of the culture and the society
through education and the embodiment of biblical principles related
to goodness and justice.
“Let the favor of the Lord our God be upon us, and establish the work of our
hands upon us; yes, establish the work of our hands!” (Psalm 90:17).
15COT0123
Introduction
The Economics of Public Health:
Missing Pieces to the Puzzle of Health
System Reform
Glen P. Mays , Adam J. Atherly ,and Alan M. Zaslavsky
The United States continues to experiment with health care delivery and financing
innovations, but relatively little attention is given to the public health system and its
capacity for improving health status in the U.S. population at large. The public health
system operates as a multisector enterprise in which government agencies work in con-
junction with private and voluntary organizations to identify health risks in the popula-
tion and to mobilize community-wide actions that prevent and contain these risks. The
Affordable Care Act and related health reform initiatives are generating new interest in
the question of how best to expand and integrate public health approaches into the lar-
ger U.S. health system. The research articles featured in this issue of Health Services
Research cluster around two broad topics: how public health agencies can deliver ser-
vices efficiently and how public health agencies can interact productively with other
elements of the health system. The results suggest promising avenues for aligning medi-
cal care and public health practices.
Key Words. Public health services, health economics, health system reform
The American pursuit of health system reform seeks to close the yawning gap
between the resources consumed by our health system and the health out-
comes experienced in the U.S. population. The fact that the United States
ranks first among high-income countries in health spending per capita but
near the bottom in life expectancy, infant mortality, and other measures of
population health and health equity is now widely understood as a public
health problem and economic burden in need of remedy. The Affordable
Care Act (ACA) and related federal and state reform initiatives have focused
attention and resources on expanding health insurance coverage and, to a
© Health Research and Educational Trust
DOI: 10.1111/1475-6773.12782
PUBLIC HEALTH SERVICES AND ECONOMICS
2275
Health Services Research
http://orcid.org/0000-0002-7837-6812
http://orcid.org/0000-0002-7837-6812
http://orcid.org/0000-0002-7837-6812
http://orcid.org/0000-0001-6443-0761
http://orcid.org/0000-0001-6443-0761
http://orcid.org/0000-0001-6443-0761
http://orcid.org/0000-0003-1072-6043
http://orcid.org/0000-0003-1072-6043
http://orcid.org/0000-0003-1072-6043
lesser extent, improving the delivery of high-value medical care. Recent
research indicates that these reforms are achieving some of their most impor-
tant intended effects on coverage and care (Courtemanche et al. 2017; Dug-
gan, Goda, and Jackson 2017; Sommers et al. 2017). Much less policy and
scientific attention, however, focuses explicitly on the larger health reform
objective of improving health outcomes in the U.S. population at large.
HEALTH REFORM AND POPULATION HEALTH
Over time, some population-wide improvements in health status are likely to
accrue from successful efforts to expand health insurance coverage and extend
high-value medical care delivery to larger shares of the U.S. population (Som-
mers, Gwande, and Baicker 2017). Accountable care organizations, patient-
centered medical homes, care transition initiatives, and value-based payment
arrangements for medical providers are all ACA-supported strategies that
have the potential to improve health outcomes for patients, and some may
simultaneously help to constrain costs (Rajkumar, Press, and Conway 2015).
These strategies by themselves, however, are unlikely to intervene strongly on
social, economic, and environmental conditions, along with health behaviors,
that collectively exert powerful influences on health status and health dispari-
ties in the U.S. population. Similarly, current health reform strategies may
have limited ability to address these health determinants far enough upstream
in order to prevent disease and injury before they occur.
Fortunately, the ACA includes significant but less visible policy and pro-
gram components designed to strengthen the nation’s public health system—
the constellation of organizations that focus on reducing disease and injury
risks in the U.S. population at large. The most prominent of these components
include (1) creation of the Public Health and Prevention Fund that expands
federal funding for public health programs and infrastructure, and (2) imple-
mentation of new requirements for nonprofit hospitals to assess health needs
in the communities they serve and to develop plans for addressing these needs
Address correspondence to Glen P. Mays, Ph.D., M.P.H., Department of Health Management
and Policy, College of Public Health, University of Kentucky, Lexington, KY, and Center for
Health Services Research, University of Kentucky, 111 Washington Avenue #201b, Lexington,
KY 40536; e-mail: glen.mays@uky.edu. Adam J. Atherly, Ph.D., M.A., is with the Department of
Health Systems, Management and Policy, School of Public Health, University of Colorado-
Denver, Aurora, CO. Alan M. Zaslavsky, Ph.D., is with the Department of Health Care Policy,
Harvard Medical School, Boston, MA.
2276 HSR: Health Services Research 52:6, Part II (December 2017)
through community benefit activities that hospitals undertake as a condition
of their federal tax-exempt status (Rosenbaum 2011). The ACA also creates
new incentives for health insurers and employers to invest in health promo-
tion and wellness programs for their covered populations. In addition, the
transition to value-based health care payment arrangements under ACA and
related federal and state reforms may create stronger incentives for medical
providers to implement public health approaches for their patient populations
and to partner with others in supporting community-wide public health initiatives.
These nonmedical components of health reform offer important oppor-
tunities for research and learning about the implementation and impact of
public health strategies and for investigating how ACA’s medical and public
health components interact in shaping health systems and health outcomes.
Historically, the health services research field has focused relatively little
attention on the organization, financing, and delivery of public health pro-
grams and their impact on health outcomes. Kerr White, a founding father of
health services research in the United States, famously eschewed research on
public health practice in favor of the study of medical practice for its more
clearly defined purposes, providers, and processes (Berkowitz 2003). Until
recently, the demand for research focused on the public health system has
been driven principally by health professionals working in local, state, and
federal public health agencies, who represent a small niche within the vast col-
lection of U.S. health system stakeholders. After all, governmental public
health expenditures constitute <3 percent of national health spending in the
United States (Martin, Hartman, and Washington 2017). Health reform and
the ACA have begun to stimulate new demand for this type of research as hos-
pitals, health systems, insurers, ACOs, and other stakeholders contemplate
new ways of engaging with the public health system (McClellan 2014). Many
health care organizations recently have created divisions focused on popula-
tion health, and the market for consultants, educational offerings, and training
programs devoted to population health continues to expand. The evidence
base on how best to expand and integrate public health approaches into the
larger U.S. health system, however, remains surprisingly thin.
UNDERSTANDING PUBLIC HEALTH AS A MULTISECTOR
ENTERPRISE
Like the medical care system, the public health system consists of a heteroge-
neous set of actors facing a mix of different incentives and constraints on their
The Economics of Public Health 2277
actions while pursuing a shared aim of improving health status (Mays et al.
2010). One class of public health actions involves the direct delivery of health
services to individuals, which is familiar territory for health services research-
ers who study medical practice. However, the personal health services deliv-
ered through the public health system tend to be those that (1) entail
significant spillover effects (externalities) on the health risks of entire popula-
tions of people, such as vaccinations and treatments for communicable dis-
eases, and (2) are incompletely delivered to the population at large through
the mainstream medical care system. A second class of public health actions
involves the implementation of policies, laws, and regulations designed to
shape the health-related behaviors and risks of large populations of people
and organizations, as in the typical subjects of health policy research. These
actions commonly focus on reducing environmental health risks in food,
water, air, soil, and the built environment.
A third class of public health interventions—perhaps the least under-
stood—focuses on stimulating and supporting collective action in society to
improve health and reduce risks. These actions aim to make organizations
from different sectors in the community more aware of health issues that they
might affect and to enlist their cooperation in pursuing solutions to these
issues. Public health agencies collect and analyze data on health needs and
risks within their communities, educate the public and community leaders
about community health needs and potential remedies, convene community
stakeholders to develop shared priorities and plans for addressing health
needs, advocate for needed health policy solutions, and recruit community
resources to support the implementation of health programs and policies.
These actions often target social, economic, and environmental determinants
of health that require engagement from nonhealth sectors such as housing,
education, transportation, social services, and business. This approach is
attracting increased attention in health policy and medical care practice as evi-
dence emerges about how unmet social and economic needs influence medi-
cal care utilization and outcomes (Alley et al. 2016).
Much of the responsibility for initiating and coordinating public health
actions falls to agencies of government—particularly state and local govern-
ment—working in partnership with an array of community organizations,
including medical care providers. The division of labor between local and
state agencies varies widely across the United States as do the roles played by
the private sector. The combinations of health programs and policies imple-
mented by public health agencies also vary widely across the United States,
driven by policy priorities of state and local elected officials and their
2278 HSR: Health Services Research 52:6, Part II (December 2017)
constituents, fiscal capacities of state and local governments, and the interest
of the private and philanthropic sectors in contributing to these activities.
The federal government plays a much more limited role in financing activities
within the public health system than it does for medical care. These structural
and fiscal realities of the public health system result in wide geographical vari-
ation in the practice of public health—another familiar circumstance for
health services researchers.
RESEARCH ON THE ECONOMICS OF PUBLIC HEALTH
PRACTICE
The challenge this poses to health services researchers is to adapt the theories
and methods honed in the study of medical practice in order to uncover the
causes and consequences of variation in public health practice. Such research
promises to point the way toward solutions that improve population health by
reducing harmful, wasteful, and inequitable variations, and by scaling up ben-
eficial innovations. Doing so can provide critical missing pieces to the puzzle
of U.S. health system reform.
Building this type of evidence requires answering some fundamental
questions about the economics of the public health system, such as the
following:
• What factors determine the mix of public health actions that are implemented in a com-
munity and the concordance of these actions with available scientific knowledge and
evidence-based guidelines?
• What resources are required to implement beneficial public health practices, and how
do resource requirements vary based on community needs and risks (IOM 2012)?
• What types of organizations and professionals are needed to implement beneficial prac-
tices, and what incentives and constraints do they face in engaging productively in this
work?
• How do public health practices influence demand for and utilization of medical care
and other social services?
• What financing mechanisms and regional delivery models are most effective and effi-
cient for supporting beneficial public health practices, and how do they vary across state
and community contexts in the United States?
• What decision tools and processes help communities to optimize their mix of public
health practices, consistent with available resources and the distribution of health needs
and risks in the community?
The Robert Wood Johnson Foundation (RWJF) has supported research
on these issues through a series of related programs implemented over more
than a decade. The Public Health Practice-based Research Networks Program,
The Economics of Public Health 2279
launched in 2007, and the Public Health Services and Systems Research Pro-
gram, launched shortly thereafter, have fostered the development of influen-
tial early studies on these topics, while also helping to refine data sources,
methods, and research-practice collaborations required for successful lines of
inquiry (Mays and Scutchfield 2015). In 2016, these programs combined to
form supporting pillars for a new Systems for Action Research Program,
launched as part of RWJF’s efforts to increase scientific knowledge on building
a culture of health across the United States (Lavizzo-Morey 2017). Systems for
Action expands the scope of scientific research on these topics by focusing
attention on how medical, public health, and social services delivery systems
interact, or fail to do so, in supporting health improvements across the United
States (Mays et al. 2016).
NEW CONTRIBUTIONS AND NEW DIRECTIONS FOR
RESEARCH
The research articles featured in this issue of Health Services Research constitute
proofs of concept for the feasibility and utility of applying the methods and
tools of health services research and health economics to the study of public
health systems. The articles in this special issue cluster around two broad
topics: how public health agencies can deliver services efficiently and how the
public health system interacts with other pieces of the health care delivery
system.
The first four articles look at questions of short-run economic efficiency
and cost in different services: environmental health inspections (Cohen and
Checko), delivery of immunizations (Basurto-Davila et al.), and sexually trans-
mitted disease (STD) partner services (Johnson et al.), and communicable dis-
ease surveillance (Atherly et al.).
Cohen and Checko used a longitudinal dataset to examine the possibil-
ity of economies of scale and scope in environmental health inspections in
Connecticut. The authors find that there are substantial economies of scale
and scope in the delivery of services. In particular, full-time municipal health
departments and regional health districts are closer to minimum efficient scale
than part-time health departments, suggesting that costs could be reduced if
smaller agencies were combined. Further, four different types of inspections
(water and septic, food and septic, food and lead, and lead and septic) have
economies of scope, suggesting total costs are reduced when the inspections
are performed together.
2280 HSR: Health Services Research 52:6, Part II (December 2017)
Basurto-Davila et al. investigated the economic gain from more efficient
distribution of vaccinations through Maine’s school-based influenza vaccina-
tion (SIV) program. Using a difference-in-difference-in-differences analysis,
coupled with a Markov microsimulation model, the authors found that the
SIV program in Maine increased immunization among children—the target
population—and lowered immunization among adults aged 18–49 years and
65 and older. On net, the more efficient targeting of immunizations was esti-
mated to have prevented 4,600 influenza infections and generated $4.9 mil-
lion in net economic benefits.
Johnson et al. examined the cost of STD partner services for HIV,
syphilis, gonorrhea, and chlamydial infections. Delivery of partner services
varied across reported disease, ranging from 96 percent for HIV cases to 17
percent for chlamydia cases. Similarly, the cost per case varied by disease
type, from a high of more than $20,000 for HIV to a low of $1,700 for syphilis.
Yet more than half of the budget for partner services was devoted to chlamy-
dial infections. This highlights the need to understand costs of services to effec-
tively prioritize public health spending.
On the question of public health interactions with the broader medical
care system, the article by Mays examined how local expenditures for public
health activities influence area-level medical spending for Medicare beneficia-
ries. Using national data on public health and Medicare expenditures in local
communities over a 20-year period, the study found that adjusted Medicare
expenditures per beneficiary fell by 0.8–1.1 percent for each 10 percent
increase in public health spending per capita. The results suggest that public
health agencies could become helpful partners to medical providers partici-
pating in Medicare’s value-based payment models and accountable health
community initiatives.
Finally, Singh and Young look at the funding question through a dif-
ferent lens: partnerships between public health agencies and hospitals.
Hospitals are required under the Affordable Care Act to spend more on
community benefits and to develop community health assessments. Given
these requirements, partnerships with public health agencies would seem to
be a natural fit. However, Singh and Young find no relationship between
public health spending and spending on community benefits by hospitals.
Further, there was little relationship between measures of community need
(broadly defined) and spending by hospitals. The potential remains for a
partnership between hospitals and public health agencies, but it is just that
—a potential.
The Economics of Public Health 2281
CONCLUSIONS
These studies add substantively to our understanding of costs and resource
use within public health systems, the availability and quality of practices sup-
ported by these systems, and the impact of these systems on important health
and economic outcomes. Several of the articles included in this issue derive
from RWJF’s pioneering research programs devoted to these topics. We hope
the work profiled in this issue will collectively help to expand awareness of
and interest in these topics in both the research and health policy communi-
ties, leading to important new avenues of inquiry and continued experimenta-
tion with innovations in public health policy and practice.
Public health proved its value during the 20th century by producing as
many as 25 of the 30 additional years of life gained by the average American
(Bunker, Frazier, and Mosteller 1994). The long-term success of 21st-century
health reform initiatives may depend in part on our ability to harness the
power of modern public health strategies to produce better health at lower cost
for the U.S. population as a whole.
ACKNOWLEDGMENTS
Joint Acknowledgment/Disclosure Statement: Support for this issue was provided
by the Robert Wood Johnson Foundation for the Systems for Action
research program (grants 61471, 74715). The guest editors acknowledge
inspiration for this issue from the work of Linda Bilheimer, Ph.D., who
passed away in 2016. Dr. Bilheimer spent her career studying economic
issues in public health at institutions that included the Congressional Budget
Office, the Centers for Disease Control and Prevention, the Robert Wood
Johnson Foundation, Mathematica Policy Research, and the Arkansas
Department of Health.
Disclosure: None.
Disclaimer: None.
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SUPPORTING INFORMATION
Additional supporting information may be found online in the supporting
information tab for this article:
Appendix SA1: Author Matrix.
2284 HSR: Health Services Research 52:6, Part II (December 2017)
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