Informatics and Federalism – Challenges in Public Health

Posted on February 15, 2024 by Abby Vogel

This entry is part 42 of 43 in the series Wide World of Public Health Systems

The United States public health system reflects a central tension of the American political system – the benefits of devolved power to address unique community concerns versus the benefits of centralized power to more efficiently achieve nationwide goals. Public health operates primarily at the state level, with no direct federal governing body despite various federal agencies exerting the power of the purse strings, and in many states the field is further decentralized to local jurisdictions. This is a direct result of the Tenth Amendment to the U.S. Constitution, in which “powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.” Thus was enshrined the idea of enumerated powers intended to limit the scope and reach of the federal government. As public health was not an explicitly enumerated power in the Constitution, purview of the discipline and its associated police powers were – and still are – reserved largely to the states. Though the federal government’s power to regulate interstate commerce and collect taxes have induced funding streams to states and local departments that may standardize certain elements of jurisdictions which receive such funding, the system is far from centralized or standardized generally. This is true of the services health departments provide as well as the data they collect.

Local and state health departments collect data from their communities for the dual purposes of upstream reporting and improving service delivery, and much more data is collected for the latter than the former. Departments also collect and maintain internal data relating to their operations, of which a limited amount is reported to external membership associations or to their state or federal government. Then, there is the data that could be collected of or about health departments to assess their capacities, services, and operating costs (like the 21C projects completed in many different states) but which isn’t currently being measured.

This surfeit of data has the potential to inform new and transformational research and policy in the public health space. As we move through the post-pandemic era and face directly the environmental and social health consequences of accelerating climate change, public health’s capacity to effectively adapt will depend on our ability to leverage data, which will require the use of public health informatics. Informatics is the science of data structures, data storage, and data algorithms, and public health informatics is that science as applied to public health practice and research.

Public health informatics will be critical to adapting to the pressures of the next century because there is no national regulatory framework for the management of data in public health; therefore, for as many health departments as currently exist in the United States (on the order of thousands), there are certainly more data management systems. As noted above, more local loci of control can allow communities to identify their own health priorities and more quickly and agilely respond to emergencies in their jurisdictions. However, the lack of centralization has created an extremely fractured data landscape both among health departments (at local, state, and federal levels) and between health departments and their clinical associates – hospitals, clinics, social services agencies, pharmacies, and more. This prevents communities, departments, and researchers from efficiently using data from different data sources (i.e., multiple local health departments, a local or state health department and hospital systems, or local and state health departments). And those that would benefit most from harmonized data management systems are the overworked and underfunded health departments that have very little time or financial resources to invest in them.

This issue is not a new one, and there are many endeavors to improve the quality of and access to public health data. The Public Health Informatics Institute is advancing the discipline of public health informatics through consulting, dissemination, and research. The Bipartisan Infrastructure Law passed in 2023 is expected to grant more than $4.5 billion to projects through the Public Health Infrastructure Grant (PHIG) dedicated to improving public health infrastructure over the next five years. One of the three focus areas of the PHIG is data modernization, recognizing the importance of creating cohesive data systems. This is a critical and greatly needed investment in the public health space, and this investment is already tackling informatics-focused projects, including an initiative led by the Public Health Accreditation Board (PHAB) to create a novel data platform that will harmonize dozens of different datasets so that their data can be used concurrently for research, analysis, and dissemination. Additionally, The Public Health Informatics & Technology Workforce Development Program through the U.S. Office of the National Coordinator for Health Information Technology was created by the 2021 American Rescue Plan and seeks to improve the public health informatics workforce for the next generation. The Center for Public Health Systems at the University of Minnesota School of Public Health is leading one of the grants from this program, the Training in Informatics for Underrepresented Minorities in Public Health (TRIUMPH) Consortium.

Despite the unprecedented financial investment in and workforce support for public health informatics, the challenges remain daunting. We must retain focus on adapting and integrating our data infrastructure as new technologies and challenges emerge for public health in the United States and across the world so that our public health systems can resiliently leverage data to preserve communities’ health in a constantly shifting environment.

Author Profile

Abby Vogel: Abby Vogel, MS, is a biostatistician whose research interests include quantitative analysis of public health topics, including systems and network analysis, inferential policy analysis, and predictive modeling. She has experience in data analytics and survey research, as well as data management and assessment development through past work with public health cost and capacity assessments. She holds a master's degree in Biostatistics from the University of Minnesota and undergraduate degrees in Mathematics, Sociology, and Neuroscience.