Swimming upstream _patient_protection_and.2

LWW/JPHMP PHH200276 January 13, 2011 17:21 Char Count= 0
Swimming Upstream? Patient Protection and
Affordable Care Act and the Cultural Ascendancy
of Public Health
Kenneth DeVille, PhD, JD; Lloyd Novick, MD, MPH
r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r r
After months of intense political infighting and
widespread public interest and commentary, President
Barack Obama signed the Patient Protection and Af-
fordable Care Act (PPACA) into law on March 23, 2010.1
The law has been applauded by supporters, and at-
tacked by critics, as the most comprehensive public
health care reform in US history. Such attention is not
misplaced. Its ultimate impact may very well rival that
of Medicare and Medicaid passed more than 40 years
ago.2
PPACA’s scope includes provisions aimed at in-
creasing access to medical care, introducing cost con-
tainment mechanisms into the public payer system (ie,
Medicare and Medicaid), and reforming private insur-
ance. As importantly, PPACA does not focus solely on
physician-providedmedicalcaretoindividualpatients.
Instead, the statute is suffused with provisions that
promise to elevate the status of, and national commit-
ment to, disease prevention, wellness promotion, and
population-based interventions. Such an approach is
not surprising. After all, Barack Obama’s 2008 “Plan
for a Healthy American” boldly declared that cover-
ing the uninsured was not enough: “Simply put, in the
absence of a radical shift towards prevention and pub-
lic health, we will not be successful in containing the
costs or improving the health of the American people
[emphasis added].”3
PPACA’s dramatic inclusion of traditional public
health staples and doctrines has led executive director
of the American Public Health Association, Georges C.
Benjamin,4
to declare that “we are at a transformative
moment in our social history. . .health reform provides
us the opportunity to reshape the way we care for our-
selves by not only expanding access to health services
but shifting away from our ‘sick care’ system.” Simi-
larly, Congressman Jim McDermott5
has observed that
thepublichealthprovisionsofPPACA“indicateamove
J Public Health Management Practice, 2011, 17(2), 102–109
Copyright C 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
toward making our system give priority to ‘health care’
rather than ‘sick care.”’ Koh and Sebelius6
of the De-
partment of Health and Human Services forecast that
PPACA “will usher in a revitalized era for prevention
at every level of society.”(p1296)
These comments and others like them suggest that
PPACA has positioned the United States on the brink of
a profound social change with respect to: (1) the “cul-
tural authority” of public health and (2) the ways in
which Americans and their government view and pro-
mote “health.” It is true that the passage and provisions
of PPACA send an undeniable signal that the dialogue
regarding health in the United States has shifted in very
real ways. PPACA and its provisions may in fact prove
to the turning point, which both signals and nurtures
the growing cultural authority of public health profes-
sionals and academics. That result is far from guaran-
teed and a number of factors will influence whether the
near future will bring progress, or regress.
● Public Health Practice or Medical Care?
While the dividing line between public health practice
and medicine is often indistinct, the classic definition
is frequently drawn from Winslow,7
who characterized
public health as the following: . . . the science and art
of preventing disease, prolonging life, and promoting
physical health and efficiency through organized com-
munity effort for the sanitation of the environment, the
Author Affiliations: Department of Bioethics and Interdisciplinary Studies,
Adjunct Department of Public Health, Brody School of Medicine (Dr DeVille), and
Department of Public Health, Brody School of Medicine (Dr Novick), Greenville,
North Carolina.
The authors thank Cynthia B. Morrow, MD, MPH and Leslie M. Beitsch, MD,
JD for their insightful comments.
Correspondence: Kenneth DeVille, PhD, JD, Professor, Department of
Bioethics and Interdisciplinary Studies, Adjunct Department of Public Health,
Brody School of Medicine, Greenville, NC 27858 (devillek@ecu.edu).
102
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Swimming Upstream? ❘ 103
control of community infections, education of the indi-
vidual in principles of personal hygiene, the organiza-
tion of medical and nursing services for the early diag-
nosis and prevention of disease, and the development
of the social machinery to assure everyone a standard
of living adequate for the maintenance or improvement
of health.(p30)
Ordinarily, public health practice focuses on pre-
ventive rather than curative approaches, on a popu-
lation rather than on an individual basis. It is clear,
though, that this dividing line is artificial and per-
meable. Physicians in medical practice often offer
preventive as well as curative care, and public health
practitioners sometimes provide curative treatments to
individual patients. The key inquiry for this discussion
is not so much which practitioners provide health care
butratherfromwhatperspectivearehealthquestionsin
policy and practice addressed—from the public health,
or the individual medical care, model—and whether
the tendency toward one approach or the other is
evolving.
● Prevention and Wellness Provisions
in PPACA
In that it purports to improve the health of the nation,
the PPACA of course might be viewed as a public health
document. The framers of the act include a wide array
ofsubstantialandspecificmeasuresaimedatfurthering
the public health approach to wellness and prevention.8
Onlyarepresentativesamplingisrequiredhere.Oneset
of provisions requires coverage of preventive services
in the clinical setting. Newly issued group-health and
insurance-plan policies (included employer-provided
insurance) are prohibited from requiring cost-sharing
(mainly co-payments) on a wide range of screening and
preventive medical care measures.9
Mandated coverage includes measures with an
“A” or “B” rating from the US Preventive Services
Task Force; immunizations10
; Health Resources and
Services Administration (HRSA) sanctioned preven-
tive care screenings for infants, children, and ado-
lescents; and certain HRSA-endorsed screening for
women.11
PPACA also eliminates co-payments on a
class of preventive services for Medicare and Medi-
caid recipients.12
Under Medicare, providers will be
reimbursed for annual wellness visits during which
comprehensive “personalized prevention plans” will
be created.13
Another PPACA provision allows employ-
ers who provide group health insurance to give their
employees discounted premiums if they participate in
wellnessprograms.14
Employerswillberequiredtopro-
vide a break time for nursing mothers for 1 year after
delivery,15
and chain restaurant and vending machine
companies must post nutritional content of all menu
items.16
On a larger scale, PPACA establishes a “Prevention
and Public Health Fund” under the Department of
Health and Human Services to support public health
programs, including research, education, screenings,
and immunization. The fund was provided an initial
appropriation of $500 million with increasing appro-
priations thereafter.17
The legislation created a National
Prevention, Health Promotion and Public Health Coun-
cil, chaired by the surgeon general to coordinate fed-
eral wellness and health promotion activities and to
advise the president on the most pressing public health
problems.18
The Department of Health and Human Ser-
vices is required to initiate a broad-based education
program focused on prevention, and health plans will
be required to develop ways to collect data, evaluate
them,andreporthowhealthoutcomescanbeimproved
by preventive measures and quality improvement ac-
tivities. PPACA authorizes the creation of loan repay-
ment programs specifically designed to increase the
public health workforce. Under the rubric of “Creating
Healthier Communities” PPACA authorizes Congress
to sponsor grants at the state level to aid public health
agencies in data collection, education, screening, and
treatment in a wide range of areas and populations. Fi-
nally, PPACA will require data collection and analysis
to identify health disparities.
● Prevention and Population Health: Has the
Time Come?
The sheer number these and other PPACA provi-
sions signal an unprecedented appreciation for public
health–related remedies and philosophy. The fact that
many of the prevention provisions of PPACA received
bipartisan support while other aspects of the act were
bitterly contested also suggests at least a partial change
in political consciousness when it comes to legisla-
tive support for the public health approach. But mixed
signals abound, and the question of the depth and
the staying power of the public health mentality-shift
remain.
As a practical matter, the ultimate impact of the pub-
lic health provisions in PPACA will depend heavily
on the implementing regulations that must be drafted
by the relevant agencies and the degree to which fu-
ture appropriations support the apparent promise of
the legislation. In “Restoring Health to Health Reform,”
Jacobson and Gostin19
applaud the historic importance
of PPACA but sound several notes of caution. Perhaps,
most importantly, the real world impact of the pro-
visions will depend on future appropriations, few of

104 ❘ Journal of Public Health Management and Practice
which are guaranteed. While grants to state and lo-
cal public health organizations are authorized by the
PPACA, effectiveness of the program will depend on
whether these future dollars materialize. The creation
of the Prevention and Public Health Fund potentially
represents the largest infusion of capital into the pub-
lic health infrastructure in U.S. history. Some public
health advocates were disappointed to discover, how-
ever, that nearly half of the first year’s $500 million
allocation was diverted to funding health professions
programs, rather than to activities that serve more di-
rectly population-health concerns. Jacobson and Gostin
note that PPACA provides loan repayment programs
to buttress the public health workforce, but lament that
the legislation “otherwise does not provide sustainable
and scalable resources to revitalize the public health
structure” at the state and community levels. Similarly,
Jacobson and Gostin are sensitive to the scant atten-
tion devoted in PPACA to reducing social disparities
that affect health. Similarly, the legislation’s attack on
health disparities seems limited to targeted attempts
to changing lifestyle and health behaviors at the indi-
vidual or community level through a series of grant-
funded initiatives. It does not acknowledge, implicitly
or explicitly, the importance of developing strategies
to influence the social determinants of health. There is
a growing recognition that social determinants exert a
powerful influence on the comparatively poor state of
health in the US compared to other industrialized na-
tions. Our willingness to implement policies to affect
these determinants is absent in this legislation, in con-
trast to certain European countries, as will be discussed
later.
As a result, Jacobson and Gostin conclude that de-
spite its extensive concern for prevention and wellness,
“PPACA takes the existing system as a given and does
little to change the fundamental dynamic of how public
health is organized, financed, and delivered.”19(p86)
● Swimming Against the Current?
While PPACA does boast a prominent preventive
agenda, realization of a broad-based public health ap-
proach may require swimming upstream against the
currents of US history, contemporary US culture, and
existing political realities. Unlike Europe, Canada, Swe-
den, Finland, and the UK, the public policy environ-
ment in the United States may slow implementation
of the preventive initiatives pioneered in PPACA and
delay indefinitely the acceptance of more expansive
and sophisticated public health visions. Growing in-
equalities in income and wealth combined with Amer-
icans’ generally and deep-seated negative attitudes to-
ward the role of government, do not provide fertile
soil for an activist and forward-looking public health
agenda. Beauchamp20
recognizes that cultural factors
often translate into practical barriers to government
protection of the health and safety of the public? The
dominant language of American political discourse,
Beauchamp observes, has long been individualism,
does not support for the benevolent restriction of vol-
untary conduct. Government prescriptions of life-style
choices, so-called public health paternalism, remain an
anathema in many regions of the United States. One
provision of PPACA requires chain restaurants to pro-
vide nutritional content for food sold to customers, an
area of regulation still viewed with special suspicion
by many US citizens. One of the authors (LN) served
previously as commissioner of health for a county in
upstate New York. Frequently he was intimately in-
volved in contentious discussions with county legisla-
tors who vehemently contended that indoor smoking
prohibitions were harbingers of “telling us what to eat
at fast-food establishments.”
JonathanOberlander21
hasruefullyobservedthat“In
the United States, the more desirable health care reform
is on substantive grounds, the less politically feasible it
is.” The history of motorcycle legislation in the United
States seems to exemplify Oberlander’s observation
and lament. Despite overwhelming evidence that oper-
ator and passenger helmets reduce deaths and injuries,
they are currently required in only 20 states.22
Federal
efforts, over the last 3 decades, to encourage states to
enact these laws have failed, and, where such laws ex-
isted, motorcycle advocacy groups have been broadly
successful in repealing them. Jones and Bayer23
reason,
understandably, that this history raises troubling ques-
tions about the realistic possibility of implementing a
thoroughgoing culture of public health that relies heav-
ily on government to protect individuals from their
own choices, even in the face of strong evidence that
these behaviors result in higher levels of morbidity and
mortality.
The cold realpolitik truth is that the funding and
implementation of the provisions of PPACA will de-
pend far more on the breadth, depth, and duration
of public support than on the well-meaning, scientif-
ically verified recommendations and exhortations of
public health authorities and academics. Attacks on
PPACA public health provisions have already begun.
The Johanns Amendment (SA 4596), offered even be-
fore the fall elections of 2010 for example, proposed
to eliminate nearly all of the funding for the Preven-
tion and Public Health Fund of PPACA.24
Although the
Johanns Amendment ultimately failed, it is emblem-
aticoftheinherentvulnerabilityofPPACA’sprevention
initiatives.
Moreover, it is axiomatic that the conditions under
which public health initiatives will flourish or wither

are directly related to the political leanings of the par-
ticular government currently in power. The vicissitudes
ofgovernmentalchange,especiallyintheUnitedStates,
aggravate this reality. International comparisons are
instructive. Consider Canada. Two provinces, Quebec
and British Columbia, were early leaders in champi-
oning broader concepts of health. Later governments,
dominated by political conservatives, downplayed of
policies and programs specifically designed to enhance
the population’s health and health promotion.25
The
dramatic shift in power from Democrat-to-Republican
in the 2010 US mid-term congressional elections will
undoubtedly affect the degree to which a consistent
public health approach is pursued at the federal level.
Observers doubt that an outright repeal of PPACA is
forthcoming, however, Republican leaders seem poised
to blunt the impact of the legislation by failing to fund
what they view as objectionable provisions.26
It is un-
clear at this point how this strategy will affect the public
health provisions of PPACA.
In contrast, countries with ideologically consistent
governments have typically been able to stay-the-
course in advancing and developing coherent public
health policy agendas, especially when the underlying
social culture is supportive of such approaches. The
apparent results are arresting. Sweden, for example,
boasts extraordinarily low levels of infant and child-
hood mortality from injury.27
Swedish life expectancy
is ninth highest in the world. These health successes
have been achieved even though the gross domestic
product per capita is relatively low, 17 of 30 among eco-
nomic cooperation and development nations.27
Signifi-
cantly though, Sweden has low levels of child poverty,
low unemployment and very high levels of public so-
cial expenditure. Income inequalities remain low.28
In
addition, social welfare policies implemented in Swe-
den during the 1920s have long been institutionalized
into Swedish government and internalized by Swedish
society. This orientation has enabled Swedish public
health officials and the population, to be receptive to
new and broader perspectives, developments and in-
novations in health promotion. In the US, activities of
public health agencies and social welfare policies have
been artificially compartmentalized undermining coor-
dinated attempts to address the social determinants of
health.
Raphael suggests that public health has been charac-
terizedby2dominantmodels.27
Thefirst,thetraditional
model (represented as well by PPACA) focuses on biol-
ogy, controlling contagious diseases and managing risk
behaviors and factors including weight, diet, tobacco
use,cholesterollevels,andsexualpractices.Thesecond,
more recent, model focuses as well on what has become
known as the “social determinants” of health. This view
of health promotion holds that the health and illness of
populations are affected not only by medical care and
lifestyle choice but also by a wide array of social factors,
including income, housing, education, human rights,
and social status and income disparities. According to
this line of analysis “The stark fact is that most disease
on the planet is attributable to the social conditions in
which people live and work.”29(e445)
While individual
health can sometimes be traced fairly directly to tra-
ditional biomedical causes, population health is corre-
lated to the social determinants of health. The social
determinants of health approach to population health
has found far more receptive homes in those cultures
and governments that have a long-standing, stable,
and consistent commitment to public health in general.
Again drawing on the Swedish example, Welfare in Swe-
den: The Balance Sheet for the 1990’s (2002) highlights the
concern of the Swedish government for general, over-
arching societal well-being. Welfare in Sweden focuses
its attention and commitment on broad social determi-
nants, which are increasingly viewed as the foundation
of health inequalities.30
A focus on social determinants
also distinguishes the Swedish approach from public
health provisions in PPACA, which emphasize almost
solely important, but limited, preventive health mea-
sures, clinical preventive services, health behaviors and
community health initiatives.
Similar to Sweden, but in contrast to the United
States, the United Kingdom has demonstrated a long-
standing concern with class-related inequality. The
Black Report (1980) revealed that despite a generation
of universal medical care, health inequalities remained
or actually increased.27
The Black Report and similar
recommendations were ignored for nearly 2 decades.
Until 1997 when the new Labour Government imple-
mented a series of policy recommendations embracing
both models of public health improvement: (1) address-
ing the social determinants and (2) risk behaviors and
factors.31
Britain’s first Minister for Public Health was
appointed and according to a Labour Party manifesto:
“A new minister for public health will attack the root
causes of ill health, and so improve lives and save NHS
money. Labour will set new goals for improving the
overall health of the nation, which recognise the im-
pact that poverty, poor housing, unemployment and a
polluted environment have on health.”32
Similarly, Re-
ducing Health Inequalities: An Action Report (1999), pro-
duced by the Department of Health in the UK, included
specific policies on health determinants of living stan-
dards, education, employment, housing, and building
healthy communities.33
In the white paper Saving Lives:
Our Healthier Nation, the UK government issued the
most explicit approach taken by any European govern-
ment to improve public health.34
Prime Minister Tony
Blair, in its forward, lauds the importance of exercise,
eating properly, and not smoking, and a strategy for

population prevention was outlined including a con-
tract to reduce the death rate from heart disease and
stroke among people younger than 65 years by at least
one-third.35
What happened next in the United Kingdom is most
instructive and illustrative of the changing fortunes
of public health, even in a country that has tradi-
tionally been receptive to such concerns. By 1999, the
newly created position of Minister for Public Health,
initially filled by Tessa Jowell, was downgraded to
the lowest ministerial rank: parliamentary under sec-
retary, diminishing its stature and influence.36
Jow-
ell’s successor carried neither the rank nor the back-
ground in social policy to spearhead the ambitious
agenda articulated merely 3 years previous.37
Con-
currently, enthusiasm and commitment seemed to
wane for the health inequalities reduction program.
As McKee31
points out the “government and its health
department have yet to show that tackling inequali-
ties in health are as important as reducing NHS wait-
ing lists and developing specialty care for people with
cancer, heart disease, and mental illness.” Thus, pub-
lic health is frequently assigned lower priority even in
single-payer systems in which healthcare and health
promotion might be more easily integrated.
The parallels with the future role of prevention in
the US health care reform are important. Consider the
stop-and-start progress of public health reform in the
United Kingdom, a country, which, unlike the United
States, is characterized by a long tradition of public
health concern and sensitivity to the social determi-
nants of health. Currently in the United States, broad-
based public health concerns cannot compete with
society’s concern with the status of individual medi-
cal care or the advocacy of the health-related indus-
tries of insurance, hospitals, and pharmaceutical com-
panies. What will be the staying power of even the
prevention initiatives when turbulence arises with the
many medical care issues that will be engendered by
PPACA?
● The Practical Implications of “Cultural
Authority” and the Battle for Hearts
and Minds
As noted, the promise of PPACA can only be fulfilled
if the regulations that will actually operationalize its
provisions embody a broader vision of health care, dis-
ease prevention, wellness promotion, and population-
based remedies. Both the content of the regulations and
the amount and placement of future funds will depend
on what might be labeled as the “cultural authority”
of public health, and the degree to which Americans
and their government view “health care” as something
broader than merely medical care for sick individuals.
In the United States, “medical care” and physicians
have become associated with individual patients, cures,
and focused scientific remedies. In contrast, “public
health” has been associated with population-health,
prevention, and the remediation through policy and ed-
ucation of unhealthy conditions.38
For a variety of rea-
sons, physicians were said to have achieved “cultural
authority” in the first one-third of the 20th century. This
cultural authority, as well as growing technical and sci-
entific competence, played a key role in the American
public’s acceptance of the use of physicians to provide
their medical care.39
As importantly for this discussion,
the medical profession’s cultural authority assured the
public’s acceptance of the medical profession’s opin-
ion and perspectives on disease, health, health care,
and policy. As a result, physicians not only dominated
health care delivery but also “enjoyed a correspond-
ing power in the domain of ideas.”40(S26)
The success of
physiciansinestablishingthissociallegitimacyandcul-
tural authority incidentally undercut the ability of other
health professionals and perspectives to influence pub-
lic opinion, governmental action, concepts of health,
and health care.
The public health perspective in the United States
has matured scientifically and conceptually over the
last century, but it has heretofore failed to command the
attention or respect accorded to physician-driven sci-
entific medicine. But, there are signs of change. PPACA
after all, includes a far larger number of public health–
related initiatives than did the failed Clinton Health
Care plan of 15 years ago. Recent historical factors and
indicators have undoubtedly broadened the public’s
view of health and health policy. A growing under-
standing and acceptance by the public of the behav-
ioral and environmental determinants of health has
increased public support both for regulation and for
voluntary, culturally driven lifestyle changes. Nearly 4
decades of rising medical costs and expenditures have
increased the interest in and commitment to preventive
health measures in general. Finally, public awareness of
the multiple threats of both bioterrorism and pandemic
flu in the last decade have highlighted the insights and
tools that public health theorists and professionals can
offer the country.40
Despite these indicators suggesting a consciousness
change in Americans’ attitude toward public health
activity and philosophy, there are reasons to believe
that the transformation, while underway, will remain
at least incomplete for some time. By almost any
estimation, the public health approach is still at
odds with the still widespread and resilient notions
of individualism, personal responsibility, and limited
government among many in the United States. The rise

of the medical profession and the medicalized view of
health were based partially on the US public’s confi-
dence and attraction to the biomedical approach to un-
derstanding and treating sickness and disease. This ap-
peal has persisted long after it has become clear that
the purely biomedical approach to disease and illness
cannot address fully the reality of environmental and
multicausal agents. As long as popular culture’s view of
sickness and health is dominated by the pure biomed-
ical approach, its understanding and confidence in the
public health model will remain incomplete. In this re-
spect, it becomes more difficult to believe that PPACA
is a revolutionary document that represents irrevoca-
ble cultural change or an absolute endorsement of the
public health philosophy and approach.
Similarly, while public engagement in the PPACA
debate was unprecedented, attention focused largely
on the issues of access to medical care, insurance, and
costs—not on the substantial public health and pre-
vention components of PPACA. As mentioned earlier,
PPACA incorporated only some of the important in-
sights of contemporary public health. For example,
Judy Monroe, deputy director for Centers for Disease
Control, recently ranked the factors that, the CDC be-
lieves, most affect health. From smallest-impact-on-
health-to-largest, these factors include counseling and
education, clinical interventions, long-protective inter-
ventions, changing the context to make individuals’ de-
fault decisions healthy, and socioeconomic factors (the
social determinants of health).41,42
Despite the identifi-
cation of “socioeconomic factors” and “changing the
context” as the most efficacious measures, PPACA pro-
visions focus predominantly on the factors labeled as
having the smallest impact, namely: clinical interven-
tions, counseling and education, and protective inter-
vention. It cannot be denied that the aforementioned
prevention activities are important to the health of
individuals, but coupling them with broader social
and environmental health determinant intervention is
necessary for maximal improvement in community
health status. Similarly, the Association of State and
Territorial Health Officials recently sponsored a con-
ference titled “Making Health Reform More Than Sick
Reform: Shifting the Focus to Better Population Health”
in which attendees could expect to “Find out the
ways in which federal health reform will attempt to
shift the current U.S. healthcare ‘non-system’ from its
sole focus on medical care and insurance reimburse-
ment, to a more rational system aimed at population-
based health and wellness.” Despite the apparent
promise of conference theme, the titles of the con-
ference presentations largely focus on preventive and
public health remedies delivered in the medical care
setting.43
● Conclusion
In sum, when the US Congress passed PPACA in March
2010, something important happened, although it is far
less than a paradigm shift. To the extent that legislation
in a republican political system is presumed to reflect
in some way the public will, the inclusion of dozens
of public health initiatives in PPACA and a reliance
on public health philosophy in the legislation seem to
suggest that a change in society’s attitude may be un-
derway. But dramatic legislative action is not always
predicated on an equally dramatic cultural transforma-
tion. Legislators, after all, respond most readily to or-
ganized interest groups and opinion leaders who help
shape the content of the legislation, rather than reflect
directlybroad-basedculturalrevolutions.Onceinnova-
tive legislation is in place, cultural change may, or may
not, follow. For example, in pioneering civil rights leg-
islation, in privacy protections, in safety and consumer
safety measures, dramatic legislative and regulatory ac-
tion preceded, instead of followed, the transformation
in public attitude. Consciousness sometimes precedes
political change, but political action sometimes inspires
consciousness change. A similar dynamic may under-
way here. Public discourse before and after passage
of PPACA was predominantly focused on access and
cost issues associated with the delivery of traditional
medical care within the traditional physician–patient
relationship—a sign that public concern is not currently
focused on public health initiatives. Nevertheless, pub-
lic health activists and groups were deeply engaged
in the drafting of the health reform bill. According to
Jeffrey Levi,44
Director of Trust for America’s Health,
a consortium of scores of public health groups “spoke
with one voice” and were able to influence the final
legislative product in a way never before possible. The
resulting legislation represents both a symbolic victory
for the public health approach and a very real oppor-
tunity to advance the public health agenda if the im-
plementation regulations and expropriations match the
word and apparent intent of the PPACA provisions. In
addition, the entitlement to such preventive care may in
time transform the public’s understanding and respect
for such measures in a broader context.
But such change will require social conversion, and
will take time. PPACA may ultimately represent a
defining moment, a crossing-over-the-Rubicon beyond
which there will be no return to old modes of think-
ing and behavior when it comes to health and health
promotion. But that result is not foreordained. What
individuals think about health influences their incli-
nations towards health services.45
Individuals consult
physicians because of their perceived susceptibility and
vulnerability to illness.46
In contrast, the public does not

experience the immediacy of public health activities:
“Turning on any kitchen faucet for a glass of drink-
ing water without hesitation or peril is a silent homage
to public health success, which would not have been
possible at the start of the 20th century.”47
The key
term here, of course, is silent homage. The spending of
state and local public health agencies constitutes only
2.4 percent of all US health care spending.48
Follow-
ing 9/11 and the apparent looming threat of bioterror-
ism, public health agencies had a new public health
protection role. Many public health officials believed
that a new era with new resources was on the hori-
zon. Although additional resources for public health
preparedness were initially forthcoming from the Cen-
ters for Disease Control and Prevention, sharp reduc-
tions in the availability of these funds followed as soon
as public attention waned. The transient nature of po-
litical power in the United States and the vulnerabil-
ities borne of difficult economic times will also be a
continuing challenge as we swim upstream. For now,
as Koh and Sebelius6
suggest, a modest “Moving pre-
vention toward the mainstream of health may well
be one of the most lasting legacies of this landmark
legislation.”
REFERENCES
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