Concerns Facing the PHS [Public Health Service]: Presented before the Interagency Institute for Federal Health Care Executives,
This speech was presented for C. Everett Koop by Richard R. Ashbaugh, Acting Director, Bureau of Medical Services, Health
Services Administration of the U.S. Public Health Services. In the speech Koop took stock of the capacities and future prospects
of the Centers for Disease Control, the Food and Drug Administration, the Health Services Administration, the National Institutes
of Health, and the other branches of the Public Health Service at a time of fiscal retrenchment.
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15 (896,134 Bytes)
1982-05-07 (May 7, 1982)
Koop, C. Everett
This item is in the public domain. It may be used without permission.
Medical Subject Headings (MeSH):
United States Public Health Service
"Challenges to the New Physician: Commencement Address, Louisiana State University Medical School, Shreveport, Louisiana"
Deputy Assistant Secretary for Health and Surgeon General
US Department of Health and Human Services
To the 60th Interagency Institute for Federal Health Care Executives
May 7, 1982
(Greetings to hosts, guests)
It's a pleasure to be here, representing the US Public Health Service at this inter-agency institute. I know Dr. Koop
had wanted very much to be here. But the World Health Organization and our government wanted him to be in Geneva. So he is
there today and I am here. In addition to being an outstanding pediatric surgeon, Dr. Koop has been for nearly four decades
an enthusiastic, dedicated teacher. I can assure you he misses this opportunity to teach.
We discussed the kinds of things you might want to know about the PHS, building on the wealth of information you've been
absorbing since April 26, which must seem like several years ago. What I would like to do, therefore, is to present a brief
overview of what the PHS looks like now . . . after some changes . . . what it will probably look like next year . . . and
what its challenges will be for the next five years.
(Presented for Dr. Koop by Richard R. Ashbaugh, Acting Director, Bureau of Medical Services, Health Services Administration,
First, you should know that the Public Health Service is far from being a monolith. It is made up of a half-dozen agencies,
each one demonstrating its own traditional streak of stubborn independence. That quality may help explain why his personnel
could chase off to Africa and Asia and wipeout smallpox or chase off after cigarette smoking in America or chase off after
senile dementia or drug abuse or the structure of DNA. In some respects, the PHS is like the fearless samurai who jumped on
his horse and rode off in all directions at once.
For more orderly approach, let me briefly review the six PHS agencies and add a seventh, the Office of the Assistant Secretary
for Health, which has line authority over the Public Health Service and will be playing a more significant role in the future.
Taking them in alphabetical order, let's start with the Alcohol, Drug Abuse, and Mental Health Administration. The title
says it all. It has three national institutes -- of mental health, of drug abuse, and of alcoholism and alcohol abuse -- they
carry out research and public education programs and, until recently, have supported a wide range of service delivery programs
at the local level . . . nearly 700 Community Mental Health Centers . . . 300 state and local drug abuse programs . . . and
about 500 state and local alcoholism projects. But more about those later.
The fiscal 1982 appropriation for ADAMHA -- as it is known in the trade -- is a bit over $400 million.
The Centers for Disease Control, or CDC, are headquartered in Atlanta. As their name implies, the centers are concerned primarily
with understanding, controlling, and or preventing communicable and vector-borne diseases. You have probably read CDC's
Mortality and Morbidity Weekly Report, the barometer of infectious disease activity in this country.
CDC's history is rooted in that strong tropical disease fraternity who labored with William Crawford Gorgas and Walter
Reed in the Caribbean, Central America, and the Philippines. Today, the centers work primarily through state and local health
authorities to -- for example -- carry out child immunizations, to control sexually transmitted diseases, and to provide the
epidemiological expertise to unravel the mysteries of legionnaires disease, toxic shock syndrome, and the latest strain of
CDC personnel are not only on TDY with state health agencies, but are also on duty overseas working to improve the screening
of Southeast Asian refugees, solving Spain's olive oil scare, or helping the WHO plan its "Extended Child Immunization
The CDC annual budget is just under a quarter of a billion dollars.
The Food and Drug Administration -- the FDA -- has been around in one guise or another for 76 years. It remains one of the
most widely publicized, praised, and vilified agencies of government. Its basic statute has two watchwords, safety and effectiveness,
that make the FDA the arbiter for public health in the marketplace of drugs, vaccines, medical devices, health supplies, radiological
gear, and certain health and medical practices, such as nutrition and diet counseling, prescription drug advertising, drugs
prescribing, and antenatal fetal diagnosis.
The FDA's budget for fiscal 82 is $330 million -- not an extraordinary sum, when you consider the mission of the FTA is
to regulate about $465 billion worth of goods and services bought by Americans consumers.
The Health Resources Administration has been concerned with three major programs:
- First, the building and maintenance of medicine's domestic, civilian physical plant. This is known as the Hill-Burton
program, named for its congressional sponsors in 1946. It's been a very successful program -- so much so that there now
appears to be about 107,000 surplus hospital beds, a costly circumstance for the nation.
- Second, the education and training of health professionals -- physicians, dentists, nurses, therapists, technicians, and
many others. Again, we are challenged by success: most estimates by private and government organizations show current or potential
"surpluses" among some medical specialties.
-And third, health planning in the state and local levels. A relatively new program, health planning has come to be the example
many observers choose when arguing for relief from federal regulations and a return to state primacy.
The Health Resources Administration has a fiscal 82 appropriation a slightly more than a quarter of a billion dollars.
The next organization, the Health Services Administration, has been the principal agency and the public health service actually
delivering -- or having agents deliver for it -- a variety of health services to "protected populations." Some examples
of these populations are American Indians and Alaskan natives, migrant workers, federal employees, coal miners, and people
living in medically underserved or unserved areas.
Until recently merchant seamen, bargemen, and canallers, riverboaters, and federal retirees were also included. They receive
their care through eight public health service hospitals and 27 clinics -- all that remained of the once extensive network
of "Marine Hospitals" begun by President John Adams in 1798. As you may know, PHS no longer operates those clinics
HSA also supports graduate medical education through student loans and scholarships. Its major component, The National Health
Services Corps, assigns 2,500 health personnel -- mostly physicians -- to provide health and medical care in underserved areas,
the quid pro quo for their government scholarship.
But in sheer size and impact, the major HSA program has been the billion-dollar Maternal and Child Health Program in such
related activities as family planning, genetic counseling, and the prevention of sudden infant death syndrome.
This year's HSA appropriation is for $2.7 billion, the second largest agency appropriation within the Public Health Service.
And that leads us to the agency with the largest appropriation, the National Institutes of Health. It's budget for fiscal
1982 is $3.6 billion, and that level should rise to $3.75 billion when we get our new budget on October First.
The 11 institutes that make up the NIH support about 15,000 extramural research projects at any one time. NIH also supports
about 2,000 intramural projects each year. Since 1937, when the forerunner National Cancer Institute was established, the
NIH has supported the work of 60 Nobel laureates in medicine, physics, and chemistry, or about the sixth of all the winners
in those categories.
The final major organizational unit within PHS is the Office of the Assistant Secretary for Health, the highest-ranking civilian
health officer in our government. Within this office are such activities as disease prevention and health promotion, anti-smoking,
support for HMOs, adolescent pregnancy programs, international health, physical fitness and sports medicine, and staff activities
like planning, evaluation, management, budget, personnel, and so on.
The OASH budget this year is $750 million. But over half of that was to have been the funding of two block grants. And that
leads me to some observations about our future.
The PHS organization I just described was what we have had during this transition year of fiscal 1982. As you know, the president
proposed -- and Congress approved -- the notion of grouping many similar categorical grant-in-aid programs into a series of
block grants to the states: one for preventive services, another for the ADAMHA projects, a third for maternal and child health,
and a fourth concerned with primary care, with the centerpiece being the community health centers program. Congress authorized
and funded the first three for this fiscal year. The fourth block grant -- the one for primary health care services -- goes
into effect October 1, 1983.
The block grants -- and the philosophy of government behind them -- are changing the configuration of the PHS. The growth
of the PHS during the past 15 to 20 years has been primarily the result of new and expanding categorical grant programs. At
the time President Reagan was inaugurated, in January 1981, the government was funding and operating 534 categorical grant-in-aid
programs, most of them delivering some service. One-seventh of those -- 74, to be exact -- were in PHS. The administration
said that it was time for the federal government to get out of the business of delivering health services, either directly
or by proxy through grantees and contractors. It's been too costly, too unwieldy, and not as effective as advertised.
Handing over those federal programs to state and territorial health authorities seemed to be preferable. Bundling them into
blocks, with as few strings as possible, was to be the method.
And PHS has had enough experience with this notion to make us optimistic. For example, nearly all of CDC's service programs
are administered through states. That relationship involves immunization, fluoridation, data collection, rat control, and
similar programs. Their record is very impressive. Another example is the Indian Health Service. Under the "Indian Self-Determination
Act," P. L. 93-638, federally recognized Tribes can decide how much federal aid they want to directly control on their
own. A number of Tribes have chosen to assume complete control over health services formally controlled and delivered by our
Indian Health Service. And that also seems to work.
The result of the block grant approach is a new division of labor within PHS. One task is simply to administer the fiscal
arrangements for the blocks. That can be done with a relatively small management staff at the assistant secretary's level.
The other task is to provide the states with any technical assistance they might need or in other ways be helpful the state
program people at their request. This task requires fewer program personnel in smaller PHS agencies.
In fact, we are currently in the process of combining both the Health Resources and the Health Services Administrations. The
former is no longer stimulating hospital construction, across-the-board undergraduate and graduate medical education, or highly
structured, federally regulated health planning. The latter no longer has the enormous categorical grant-in-aid service programs
that are now part of the blocks.
The president hopes that the block grant approach, in addition to breathing new life into American federalism, will also tend
to reduce the growth rate federal health funding. This is one of the fastest-growing line items in the federal budget. In
1965, a benchmark legislative year, federal spending for health totaled $5 billion. That would include the VA and the National
Science Foundation, for example, as well as the PHS. By 1980 the total had risen to $71 billion -- a 14-fold increase. Obviously,
if the President is looking for so-called "targets of opportunity" for cooling down the federal budget, what better
place to start than the public health budget?
But even that is an oversimplification. While some health agencies may receive reduced appropriations, some public health
functions will need -- and get -- more money. This is seen most clearly in the research area.
When the President gave his "State of the Union" address last January, he specifically noted that "research at
the National Institutes of Health will be increased by over $100 million." The subsequent budget proposals for fiscal
1983 actually show a $109 million increase for the biomedical research supported by NIH and a $27 million increase for the
predominantly behavioral research supported by ADAMHA.
Now, armed with all this information, you can begin to see what the world of PHS may look like over the next five years. Let
me sketch the outline for you now:
1. We will be returning to what had been our traditional role as a partner . . . an equal among equals . . . with colleagues
in health and medical care at other levels of government and private non-profit and for-profit organizations. More initiatives
for improved health and medical care will spring from among those groups than may have been the case in the recent past. The
opportunities will be there, since the federal role is being reduced, brought back down to a more reasonable scale. Federal
expertise will reside more in substance, in the ability to negotiate among competing interests on the public's behalf,
and in the stewardship of the National Health Agenda.
2. Aside from the "housekeeping role" of fiscal management of the blocks, the PHS retains -- and is expected to strengthen
-- its role as a principal supporter of basic biomedical and behavioral research. Only the federal government can assemble
the extraordinary resources and personnel, money, facilities, and time and invest them over the long term in such projects
is unlocking the genetic code, identifying the fundamental mechanisms of human immunology, developing monoclonal hybridoma
technology, and, of course, the research required to be the major killers in society: heart disease, cancer, and stroke.
3. The great structure built to carry out the delivery of health services was predicated on medical practice that was essentially
curative and reparative. It was essentially post-facto medicine. One of the things we've learned from research and experience,
however, is that the most effective tools we have to improve health status are prevention and health promotion. There would
never have been enough money in the world to take care of heart disease and cancer victims -- if there had been no campaign
to get people to quit smoking. We would never have been able to care for the children and adults, struck down by polio, diphtheria,
measles, and typhus, had there been no program of mass childhood immunization.
The logic of this is so overwhelming that the prevention of disease and disability in the promotion of good health and well-being
are now the keystones of national health policy. One of the most exciting developments in the years ahead, therefore, will
be the maturing of this concept as a fundamental tenet of American public health policy and practice. And contributing to
this process will be an important function of the federal health enterprise, whether through research or public education.
I hope this brief overview of where we are and where we are heading has helped you get some additional perspective on the
US Public Health Service. We've come a very long way over the past 184 years. We anticipate a fruitful journey for the