In the April 1, 2009 edition of the American Journal of Public Health, Dr. Thomas Farley, professor and chair of the department of community health sciences at the Tulane University School of Public Health and Tropical Medicine, expanded the discussion of universal health care by proposing that reforms look beyond access to care to the behaviors that are the most powerful determinants of health. Dr. Farley is also the director of the Prevention Research Center at Tulane University. His editorial is titled "Reforming Health Care or Reforming Health?"

While a more comprehensive national health care plan may be called for, Dr. Farley posited, larger gains could be seen if a greater focus was put on the behaviors and environments that lead to chronic disease.

Dr. Farley’s editorial cites studies that show only modest decreases in mortality by increasing access to health care. Greater success could be generated through wider, population-based approaches. He uses cancer as an example. Cancer rates are falling, he stated, but not because of cures, treatments, or screenings. Rather, they are falling due to the decline in smoking over the past 40 years, a decline prompted by taxes, smoke-free air laws and counter-advertising initiated by activists not by agencies.

Health reform to bring about similar improvements for chronic disease will require a change in the way that public health agencies operate, he said.

"Public health professional need to become activists," Dr. Farley concluded.