It is time to boldly expand the scope and reach of public health to address all factors that promote health and well-being, including those related to economic development, education, transportation, food, environment, and housing. Despite nearly $3.0 trillion in annual health care spending, the United States ranks 27th in the world in life expectancy, and relatively low in many other measures of health and well-being. Worse yet, for the poor in this country, life expectancy is actually decreasing. Given these trends, and persistent gaps in health status, it’s time for a major upgrade to Public Health 3.0.

This commentary describes data for action, including trend data about workforce demographics, needs, gaps, impact, and programs and tools, which are essential for planning, implementing, and evaluating workforce development programs and activities across all levels and jurisdictions. | One infectious disease can change everything, at any time: Ebola. One storm can change anything, at any time: Hurricane Katrina. One technological innovation can change how people relate to one another, learn, and connect: smartphones. One tipping point in social vigilance can result in the resurgence of a disease once controlled: measles. One policy can catalyze transformation: the Affordable Care Act. | How do we recruit, train, support, and retain a public health workforce capable of working in this highly connected, fast-changing environment? This is an important question for governmental public health across all levels and jurisdictions. | It is imperative to have data for action, including trend data about workforce demographics, needs, gaps, impact, and programs and tools. This information is essential to planning, implementing, and evaluating workforce development programs and activities and for ensuring that workforce investments are well spent

Public health services and systems research (PHSSR) provides the evidence and scientific foundation for increasing understanding of the public health system, supporting health system improvements, and advancing the field of public health practice. A focus on the "system" in "public health systems and services research" remains as important as ever and is becoming more complex over time.

The findings described in this supplement can help improve collaboration among public health and other stakeholders who influence infant, child, and adolescent health (e.g., parents or guardians and their employers, health plans, health professionals, schools, child care facilities, community groups, and voluntary associations) to increase the use of selected clinical preventive services among U.S. infants, children, and adolescents. Increased use can substantially reduce illness and long-term disability and improve health and quality of life. This supplement underscores that the use of the clinical preventive services among U.S. infants, children, and adolescents is not optimal and is variable, ranging from <10% to approximately 85%, depending on the particular service. Use was particularly low for developmental screening and receipt of dental preventive services in young children, and for human papillomavirus (HPV) vaccination and tobacco cessation assistance, including counseling, in adolescents; however, opportunities exist to improve use of all of these services. Children and adolescents with no insurance and those with no usual source of health care (if available for analysis) were the groups least likely to have used the services. Use among the uninsured ranged from 1-39 percentage points below the general population averages, suggesting that improvements in insurance coverage that will result from the implementation of health-care reform are likely to increase use of these clinical preventive services. In 2012, a total of 4.9 million children (6.6% of children) were uninsured at the time of interview, and approximately 15% of eligible children in the United States are not enrolled in Medicaid and Children's Health Insurance Program (CHIP) programs. In addition, although opportunities exist for greater insurance coverage and for use of recommended clinical preventive services under the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152, together referred to as the Affordable Care Act [ACA]), a survey among the uninsured found a low level of awareness of the Health Insurance Marketplace (or Health Insurance Exchange) that can be used by families to acquire insurance or Medicaid coverage. The survey highlights the importance of focused efforts by governmental health agencies and other stakeholders to enroll uninsured children and adolescents in health plans. Also, although use of clinical preventive services in insured populations was greater than among the uninsured, use among the insured was generally <85%, and often much less. Therefore, having health insurance coverage alone might not be sufficient to optimize use of clinical preventive services, and additional measures to improve use probably will be necessary.

America faces a new frontier in preventing chronic disease. Nearly 80% of the 10,000 people who turn 65 each day have at least 1 chronic health condition, and most have multiple chronic conditions (1). The costs of braving this new world are staggering, especially given the nation’s strained economy and budget cuts that have forced health departments to reduce their workforce and impose furloughs and reduce or eliminate chronic disease programs. Despite these daunting challenges, government public health agencies have opportunities to be the driving force behind improving the nation’s health. | The Office for State, Tribal, Local, and Territorial Support (OSTLTS) at the Centers for Disease Control and Prevention (CDC) was established in 2010 to better position CDC to support health departments. The mission of OSTLTS is to advance US public health agency and system performance, capacity, agility, and resilience (2). OSTLTS recognizes health departments as the front line of prevention and promotes a systems approach that works across sectors, partners, and programs to address the complex community and economic challenges that affect the public’s health. | An important and recent advancement in the practice of public health is the establishment of a national public health accreditation program and the Public Health Accreditation Board (PHAB). Funded by OSTLTS and the Robert Wood Johnson Foundation, PHAB seeks to advance the quality and performance of public health departments through national standards, which more than 3,000 health agencies can use to continuously improve performance. Based on the 10 Essential Public Health Services (3), PHAB accreditation offers a means to ensure comprehensive and quality programs for a range of public health areas, including chronic disease prevention. In March 2013, the first 11 public health departments were accredited by PHAB, and many more applications are in process (4).

The findings described in this supplement can help improve collaboration among public health and other stakeholders who influence population health, including employers, health plans, health professionals, and voluntary associations, to increase the use of a set of clinical preventive services that, with improved use, can substantially reduce morbidity and mortality in the U.S. adult population. This supplement highlighted that the use of the clinical preventive services in the U.S. adult population is not optimal and is quite variable, ranging from approximately 10% to 85%, depending on the particular service. Use was particularly low for tobacco cessation, aspirin use to reduce risk of cardiovascular disease, and influenza vaccination; however, ample opportunity exists to improve use of all of these services. Among the specific populations least likely to have used the recommended services, persons with no insurance, no usual source of care, or no recent use of the health-care system (if included in the analysis) were the groups least likely to have used the services. Use among the uninsured was generally 10 to 30 percentage points below the general population averages, suggesting that improvements in insurance coverage are likely to increase use of these clinical preventive services. A randomized, controlled trial of an expansion of Medicaid coverage by Oregon in 2008 supports this hypothesis by demonstrating improved use of clinical services with increased health insurance coverage. A recent survey among the uninsured found a low level of awareness of the provisions of the Patient Protection and Affordable Care Act of 2010 as amended by the Healthcare and Education Reconciliation Act of 2010 (referred to collectively as the Affordable Care Act [ACA]). Therefore, improving opportunities for coverage might be insufficient, and focused efforts by governmental health agencies and other stakeholders are likely to be needed to enroll uninsured persons in health plans. In addition, although use of the preventive services in insured populations was greater than among the uninsured, use among the insured was generally <75%, and often much less. Therefore, having health insurance coverage might not itself be sufficient to optimize use of clinical preventive services, and additional measures to improve use are likely to be necessary.

We commend Sprague Martinez et al.(1) for highlighting neighborhood sanitation conditions recognized by local Black and Latino youths who then photographed these social and environmental conditions that related to their personal stress. Their experience once again demonstrates the importance of engaging community members in assessing the health of their own communities. (Am J Public Health. Published online ahead of print September 20, 2012: e1. doi:10.2105/AJPH.2012.301018).

The field of public health services and systems research (PHSSR) has emerged over the past decade to produce the evidence needed to address critical uncertainties about how best to organize, finance, and deliver effective public health strategies to all Americans. To advance these efforts, a national PHSSR research agenda-setting process was used to identify a broad inventory of information needs and uncertainties that public health stakeholders face in the domains of public health workforce, public health system structure and performance, public health financing, and public health information and technology. This paper presents the results of an expert review process used to transform the identified information needs into a concise set of research questions that can be pursued through new scientific inquiry in PHSSR. Established research frameworks were used to specify the contexts, mechanisms of action, and outcomes within the public health system that require further study. A total of 72 research questions were developed from the 113 original items in the PHSSR inventory of information needs. The questions include both persistent problems and newly emerging needs in public health practice and policy. The resulting research agenda provides a starting point for mobilizing the public health scientific enterprise around contemporary, high-priority uncertainties identified by broad cross sections of public health stakeholders. Regular updates to this agenda will be required to achieve continuous improvements in both the science and practice of public health.

For years we have known the value of assessing the delivery and effectiveness of individual clinical services and how factors such as structure, organization, and finance influence the quality and quantity of clinical care. There is a comparable field in public health called public health services and systems research (PHSSR) that studies system-level factors and their association to public health delivery and the health of populations. Mays and colleagues1 have defined public health services and systems research as a field of study that examines the organization, finance, and delivery of public health services in communities and the impact of these services on public health. | Two more recent efforts2, 3 have focused on expanding and further enhancing that early definition. Scutchfield et al.2 suggested that PHSSR would benefit from an enhanced definition that emphasized the following: | • | PHSSR is closely related to its parent discipline of health services research. | • | Health services provided by categorical public health programs can be strengthened by an understanding of PHSSR. In a similar way, the understanding of public health infrastructure could be enhanced by an understanding of principles that can be learned from categorical public health programs and the direct patient care they deliver. | • | The nexus of clinical care and public health in an era where there is a renewed call for bridging public health and primary care, particularly in the wake of population health having become a component of health system reform.

Systems research is not new; it routinely has been used in chemistry, biology, ecology, economics, and epidemiology for many years and has been applied toward understanding the public health system for nearly 2 decades. During that time, the CDC, other operating divisions within the DHHS, and several international organizations have been using systems research to advance the field of public health. The CDC has made major contributions through developing the National Public Health Performance Standards Program, the precursor to accreditation of health departments, and leading the establishment of the first national public health systems research agenda in 2006. The CDC also has funded nine Preparedness and Emergency Response Research Centers that are pursuing a multidisciplinary public health systems research approach to improving preparedness and response. Each of these research centers is yielding important results that are relevant to policy and practice. | Elsewhere in DHHS, systems research is being applied to other public health problems. For instance, the NIH is applying systems research to the complex issue of health literacy, a problem that affects people's access to care, skills in comprehending and acting on health information, and decision making about behavior change such as healthy eating and exercise. (obssr.od.nih.gov/scientific_areas/social_culture_factors_in_health/health_literacy/index.aspx). In June 2011, the Health Resources and Services Administration released a tool kit, based on systems thinking and systems analysis, for mapping state child health care.1 The Administration for Health Research and Quality is also using systems research and design to understand and improve the complex socio-technical system of healthcare delivery in the U.S. (www.ahrq.gov/qual/systemdesign.htm).

Contemporary public health is faced with numerous challenges including health disparities, a rise in chronic conditions, non-intentional and intentional injuries, premature birth, disabilities, and unsafe environments. The economic recession has led to cuts in state public health budgets, and medical expenditures have risen exponentially. Health departments are more effective when they have strong clinical partners, and physicians need the support of public health services. Socioeconomic conditions and public policy have larger impacts on health threats than clinical interventions and individual counseling. Integrating public health education across the spectrum of medical education is a strategy for achieving greater collaboration between medicine and public health. The imperative for this collaboration is even greater with the passage of the Affordable Care Act and the advancement of information technology. Our nation needs the physician workforce to understand the determinants of health and the policies and environmental changes that will alter the context to make the healthy choice the default choice. We need more physicians playing an active role in policy advocacy and in leadership roles in their communities, states, and nationally. And we need more physicians to understand prevention and population health. | My experience as a family physician practicing in Appalachia, directing a residency program, serving as a state health official, and now in a leadership role at the CDC, has afforded me the opportunity to experience both worlds of medicine and public health.