In the USA, responsibilities and authorities for health services are spread across federal, state, and local levels of government. In addition, certain nongovernmental organizations perform critical functions regarding the provision and influence of public health policies.
The Constitution contains no legal basis for the provision of health care to the general population. Therefore, as per the Tenth Amendment, this responsibility automatically falls to the states. When the federal government directly influences national health care issues, it generally does so under the auspices of the Constitution’s Interstate Commerce Clause, which gives Congress the power “to regulate commerce with foreign nations, and among the several states, and with the Indian tribes.” The federal government also significantly influences health care issues in an indirect fashion through the provision of federal funds. Commonly, funds allocated to state and local governments for health issues are contingent on that entity participating in national programs such as disease reporting and adhering to national health goals and standards.
The Department of Health and Human Services (DHHS) is the primary public health agency at the federal level and serves to assess the general health of the nation, establish national goals and policies, and direct federal efforts in support of the states. Major public health–oriented components of DHHS include the Agency for Healthcare Research and Quality (AHRQ), the Agency for Toxic Substances and Disease Registry (ATSDR), the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the Health Resources and Services Administration (HRSA), the Indian Health Service (IHS), the National Institutes of Health (NIH), and the Substance Abuse and Mental Health Services Administration (SAMHSA).
Other federal departments with significant equities in national health care and public health responsibilities include 1) Department of Agriculture (USDA), which is responsible for meat inspection and disease prevention and control; 2) Department of Defense (DoD), which is responsible for health care policies and provision of health care for active duty members, family members, and retirees; 3) Department of Homeland Security (DHS), which is responsible for disaster planning and response; 4) Department of the Interior (DoI), which operates the National Park Service (public health and disease outbreak investigations on National Park lands), the Bureau of Indian Affairs (treaty obligations to tribes, including provision of health care and environmental health infrastructure projects), and the Bureau of Reclamation (provides potable drinking water and agricultural irrigation water to much of the western USA); 5) Department of Veteran Affairs (VA), which is responsible for health care policies and provision of health care for qualified veterans, and administers significant civilian medical education systems; and 6) Environmental Protection Agency (EPA), which sets and enforces national environmental health standards.
The state is the primary public health legal authority. Although specific activities and delegations may vary from state to state, state public health responsibilities generally include the following: 1) collection and maintenance of vital health data, 2) maternal and child health, 3) diagnostic and public health laboratories, 4) state-wide nutrition programs, 5) regulation of health facilities (including nursing homes), 6) environmental health programs (eg, safe drinking water, waste treatment), 7) state Medicaid program, and 8) regulation and licensing of medical professionals (eg, veterinarians, physicians, dentists, etc).
Local public health agencies are structured and empowered to provide services where they are most effective—at the community level. These services may be primary or delegated from the state level and commonly include the following: 1) immunizations not covered under private insurance systems, 2) disease surveillance and investigation, 3) communicable disease control, 4) inspection and licensing of food establishments, 5) public health screening programs, 6) tobacco control programs, 7) disaster preparedness and response, and 8) care for the underserved, indigent, and disabled.
An NGO is any nonprofit, voluntary citizens group organized on a local, national, or international level. Task-oriented and staffed by individuals sharing common interests, NGOs perform a variety of service and humanitarian functions. Functions of health-oriented NGOs may include raising citizen concerns to governments, advocating and monitoring health policies, and encouraging political participation through public information dissemination. NGOs that exist and act domestically (and overseas in some cases) in the public health sector include the American Red Cross, the American Cancer Association, the American Lung Association, the CDC Foundation, Heifer International, the March of Dimes, and the Bill and Melinda Gates Foundation.