For immediate release
Tuesday, July 11, 2006
12:01 a.m. EDT


Christopher Fleming

In Health Affairs July/August Theme Issue On Public Health, Studies Question Whether Public Health Infrastructure Is Prepared For New Challenges 
Leading Health Policy Journal Also Looks At Personal Assistance Workforce, Cost Sharing In Consumer-Driven Care, And Impact Of Electronic Health Records

Bethesda, MD — A two-decade trend of increasing numbers of public health workers could reverse if the federal government decreases support for anti-bioterrorism activities, health experts warn in a study appearing in the July/August 2006 issue of the journal Health Affairs. “This study is a wake-up call for federal, state, and local policymakers to look broadly at public health needs now and in the future,” said lead author Kristine Gebbie of the Columbia University School of Nursing.

Concerns over terrorism, emergency preparedness, and such threats as pandemic influenza have helped expand and strengthen the public health workforce in recent years, according to Gebbie and coauthor Bernard Turnock of the University of Illinois at Chicago School of Public Health. But despite the increased attention and resources given to public health, policymakers are grappling with decreasing numbers of workers at the state and local levels; impending shortages of experienced workers to replace retiring ones; insufficient education and training; and inadequate incentives that recognize and reward skills and performance, the researchers write.

What’s in the issue. Gebbie and Turnock’s study is just one of many papers on public health featured in the new Health Affairs issue, which is titled “The State of Public Health” and was funded by the Robert Wood Johnson Foundation. http://content.healthaffairs/org/current.shtml. Another study featured in the issue concludes that public health resources are insufficient to keep pace with the changing demands of the public health system, especially given new concerns about bioterrorism, pandemic disease, and hurricane response. Public health spending accounts for less than 2.5 percent of total health care spending, according to the study. Mean per capita spending for public health in 2004-2005 was $149, compared with $6,423 for overall health care spending and $254 for protective services from police.

“Public health is underfunded to meet the demands of an aging population and is further threatened by terrorism and natural disasters. As health departments take on new roles and responsibilities, old functions are rarely jettisoned,” said lead author Leslie Beitsch, director of the Center for Medicine and Public Health at the Florida State University College of Medicine. The work of Beitsch and his coauthors is based on 2005 surveys of state and local public health agencies conducted by the Association for State and Territorial Health Officials (ASTHO) and the National Association of County and City Health Officials (NACCHO).

Additional highlights of the issue include the following:

Personal Assistance Workforce. A large and steady fifteen-year gain in the number of personal assistance workers, who provide critical services that let millions of disabled and elderly Americans remain at home and out of institutions, could be coming to an end.

The ranks of these workers could begin to decline due to cuts in Medicaid, persistently low wages, scarce health benefits, and high job turnover, says a new study in the July/August issue. If conditions do not improve, researchers warn, attracting and retaining skilled workers who provide personal assistance could become increasingly difficult, even though the number of people needing these services will more than double by 2050.

“The aging of the population is going to trigger an increased demand for personal assistance services over the coming decades, but there is no guarantee that the workers will be there to treat them,” said study lead author H. Stephen Kaye, a professor in the Institute for Health and Aging at the University of California, San Francisco. “If nothing is done to reverse the trend, we could see precipitous declines in the personal assistance workforce, reverting to low levels that we haven’t seen in years,” he warns.

Cost sharing and consumer-driven care. Combining high-deducible health plans with tax-favored health savings accounts (HSAs) is often touted as a way of giving consumers more of a financial stake in their health care decisions. But a new study in the July/August Health Affairs finds that such “consumer-driven” coverage arrangements would actually result in reduced or unchanged cost- haring, both on average and at the margin, for consumers responsible for more than half of the health care expenditures.

Proponents of consumer-driven health care say that people with more “skin in the game” will consume health care more prudently. However, because HSA/high-deductible plans impose almost all of their cost sharing through deductibles, they leave untouched the high spenders who are responsible for the bulk of health care expenditures, say Health Affairs coauthors Dahlia Remler, an associate professor in the Baruch College School of Public Affairs, and Sherry Glied, chair of the Department of Health Policy and Management at Columbia University’s Mailman School of Public Health. The authors also point out that in today’s marketplace, the typical comprehensive health plan already imposes substantial cost sharing on consumers.

Cost Savings From Electronic Health Records? Some observers have claimed that electronic health records (EHRs) could bring substantial cost decreases and quality improvements. But in the July/August Health Affairs, Jaan Sidorov writes: “A considerable body of research suggests that widespread adoption of the EHR increases health costs.” Sidorov, an associate in the Department of General Internal Medicine at the Geisinger Medical Center in Danville, Pennylvania, focuses on the use of EHRs in ambulatory care settings but says that his conclusions are likely to apply in the inpatient arena as well.

Sidorov points out that EHRs often lead to higher billings and declines in providers’ productivity with no change in provider-to-patient ratios. He also notes that error reduction from EHRs is inconsistent and has yet to be linked to savings or malpractice premiums. Sidorov suggests that “the EHR’s greatest value arguably lies in support of” potentially transformative initiatives, such as disease management and patient-centeredness, “versus the prospect of less efficiency, greater cost, inconsistent quality, and unchanged malpractice burdens resulting from a simple engraftment [of EHR] onto the current health care system.”

Health Affairs, published by Project HOPE, is a bimonthly multidisciplinary journal devoted to publishing the leading edge in health policy thought and research. Copies of the May/June 2006 issue will be provided free to interested members of the press. Address inquiries to Christopher Fleming at Health Affairs, 301-347-3944, or via e-mail, All articles are available online, a selection of which are available at no cost, at The public may order print editions of the May/June issue for $35 each from Health Affairs’ Customer Service at 301-347-3900 or online at



Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at


©2006 Project HOPE–The People-to-People Health Foundation, Inc.