The Future of Public Health:

Improving Health Impact

“The Affordable Care Act

Implementation in a Changing Environment”

Dean‟s Lecture

University of North Carolina

Gillings School of Global Public Health

Chapel Hill, NC

January 27, 2011

Georges C. Benjamin, MD, FACP, FACEP(E), FNAPA, Hon FRSPH

Executive Director

American Public Health Association

“Protect, Prevent, Live Well”

2

Some Things Are Just True

“If you always do what you always did

then……

you‟ll always get what you always got”

Moms Mabley

3

Just To Remind Everyone:

Why We Did Health Reform

Costs Unaffordable to individuals

Excessive growth in overall costs

Quality & safety concerns Uneven & inconsistent

Disparities in outcomes

Preventable medical errors

Access Rising un/underinsured

Less provider availability

Inadequate use of Health IT Clinical information

Program management

Sickness versus wellness Under investment in public health

More focus on disease end of process

4

Patient Protection and

Affordable Care Act

Major health policy achievement

Achieves 94% health coverage

Major insurance reforms

Promotes prevention & wellness

Promotes primary care

Increase value & quality for

health dollar

Reduces deficit by $143 billion

Increases affordability for many

Supports modern HIT system

5

Implementation Challenges

Expanding insurance coverage

Insurance card does not equal

access

Increased need for safety net

Catch patients who fall through

the cracks

Provide services to expanded

population

Reinforcing, adjusting,

remodeling core public health

programs

Implementing new public health

programs

6

Implementing New Programs

In A Recession / Recovery

Central challenge because:

States under fiscal stress

Federal budget challenges

More needs than money

Hiring freezes

Training reductions

Limited infrastructure

Other urgent priorities

Legislative requirements

History of underfunding and Yo-Yo funding

Supplantation is biggest challenge (Federal, state & local)

7

Public Health In A Near

Universal Coverage Environment

Policy development, assessment and indirect assurance roles will increase

Direct assurance role will decrease

Need to remodel public health programs

Ryan White

CDC breast & cervical cancer

Pharmacy assistance

Chronic disease control

Preparedness

Immunization

Many others

Must capture & reapply savings

8

Covers 32 Million More

Nonelderly People

Health Reform

Coverage Plan

Medicaid to 133% FPL

~ $29,000

Rest

400% FPL or

< $88,000

---------------------------

> $88,000

Medicare Reforms• Cheaper medications

• Care coordination

• New prevention benefit

Under age 65 Age 65 & older

9

Expands Safety Net

Health Care System

Creates a Community Health Center Fund - $10 billion over 5 years Enhances funding for the

Community Health Center program

Construction and renovation of community health centers

Capital grants to support school-based health centers especially in underserved communities $50 million appropriated for

each of the fiscal years FY 2010 - 2013 for expenditures for facilities and equipment or similar expenditures.

10

Fiscal Impact Of Increased

Coverage: Public Health Programs

Potential for increased revenues

Billing & collecting challenges

Uncompensated services

Revenue stream to general fund versus agency

Potential for decreased revenue from grants / contracts

Uncompensated population based services

Uninsured populations

11

Need To Adapt Safety Net Program:

Pharmacy Assistance

Medical Assistance - Receive complete pharmacy services.

HealthChoice - Receive most mental health drugs and AIDS/HIV drugs - All other drugs are provided by HealthChoice Managed Care Organizations (MCOs).

Primary Adult Care (PAC) -Receive most mental health drugs and AIDS/HIV drugs - All other drugs are provided by PAC Managed Care Organizations (MCOs).

Family Planning - Receive only contraceptives.

Medicare Part D - Fully dual eligible Medicare beneficiaries receive most drugs excluded from Medicare Coverage -- All other drugs are provided by Medicare Prescription Drug Programs (PDPs).

Example: State of Maryland

12

Prevention & Wellness Services:

Essential Health Benefits

Coverage of Preventive Health Services – All group health plan and health insurance issuers offering group or individual health insurance coverage must now provide coverage for and shall not impose any cost sharing requirements for:

Evidence based items or services that have a rating of „A‟ or „B‟ in the current recommendations of the US Preventive Services Task Force (USPSTF);

Immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) of the CDC;

Evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by HRSA for infants, children, and adolescents;

For women, any additional preventive care and screenings provided for in comprehensive guidelines supported by HRSA; Uses original breast cancer screening, mammography, and prevention guidelines (not those issues around November 2009)

Prevention and coverage required in the bill are a floor & not a ceiling

Strengthens USPHTF & Community Preventive Health Task Force

13

Vaccine Preventable Diseases

Authorizes states to obtain additional quantities of adult vaccines through the purchase of vaccines from manufacturers at the applicable price negotiated by the Secretary

Authorizes a demonstration program to improve adult immunization coverage.

Reauthorizes the Immunization Program under Section 317 of the Public Health Svc Act.

Requires a GAO study and report on Medicare beneficiary access to vaccines and coverage of vaccines under Medicare Part D.

14

Impact of Increased Insurance Coverage

For Preventive Services:

The Vaccines for Children Program

Eligible children through age 18

Medicaid eligible

Uninsured

Underinsured A child who has commercial (private) health

insurance but the coverage does not include vaccines

A child whose insurance covers only selected vaccines (VFC-eligible for non-covered vaccines only)

A child whose insurance caps vaccine coverage at a certain amount. Underinsured children are eligible to receive VFC vaccine only through a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC)

Children whose health insurance covers the cost of vaccinations are not eligible for VFC vaccines

American Indian or Alaska Native:As defined by the Indian Health Care Improvement Act (25 U.S.C. 1603)

15

State Vaccine Programs Will Change

Universal vaccine states

Health departments that

do few direct vaccinations

States where providers

don’t do vaccinations

Maintain disease

outbreak vaccination

response capacity

Maintain regulatory &

oversight capacity

16

Impact Of Coverage On The CDC

Breast & Cervical Cancer Program

Provides cancer screening services for women uninsured or underinsured women at or below 250% of federal poverty level

Linkage to specialists

Support services & other health screenings

Continuity of care & access issues to address during transition

Coverage creates challenges

17

National Prevention, Health Promotion

& Public Health Council

Provide coordination and leadership at the Federal level Prevention, wellness and

health promotion practices, the public health system and integrative health care in the U.S.

Develop a National Prevention Strategy: Sets goals and objectives for

improving health through federally-supported prevention, health promotion and public health programs

Establish measurable actions and timelines to carry out the strategy

Make recommendations to improve Federal prevention, health promotion, public health and integrative health care practices. Headed by U.S. Surgeon General

18

National Prevention, Health Promotion

& Public Health Council 2010 Report

Principles

Prioritize prevention and wellness

Establish a cohesive federal response

Focus on preventing the leading causes of death, and

the factors that underlie these causes

Prioritize high-impact interventions

Promote high-value preventive care practices

Promote health equity

Promote alignment between the public and private

sectors

Ensure accountability

19

National Prevention, Health Promotion

& Public Health Council Recommended

Strategies For Effective Action

1. Policy

2. Systems Change

3. Environment.

4. Communications

and Media

5. Program and

Service Delivery

20

Council‟s Initial Areas of Focus

Diseases

Cardiovascular disease

Cancer

Lower respiratory

disease

Unintentional injury

Behavioral health

Behaviors

Tobacco use

Nutrition

Physical inactivity

Early alcohol use/ abuse

Seeking Public Input For Next Report

21

Prevention & Wellness Fund

Fund to expand and sustain a national investment in prevention and public health programs (Over FY 2008 level)

Support programs authorized by the Public Health Service Act, for prevention, wellness and public health activities

Funding levels: FY 2010 - $500 million

FY 2011 - $750 million

FY 2012 - $1 billion

FY 2013 - $1.25 billion

FY 2014 - $1.5 billion

FY 2015 and each fiscal year thereafter - $2 billion.

22

Community Transformation Grants

CDC awarded competitive grants for the implementation, evaluation, and dissemination of evidence-based community preventive health activities to:

Reduce chronic disease rates

Prevent the development of secondary conditions

Address health disparities

Develop a stronger evidence-base of effective prevention programming

Activities may focus on creating: Healthier school environments

Creating infrastructure or programs to support active living

Access to nutritious foods

Smoking cessation and other chronic disease priorities

Implementing worksite wellness

Working to highlight healthy options in food venues

Reducing disparities and addressing special population needs

Includes evaluation and reporting requirements.

23

2010 Expenditures

Prevention & Public Health Fund

The $250 million for prevention and public health to:

Community and Clinical Prevention: $126 million Support federal, state and community prevention initiatives

Integrate primary care services into publicly funded community-based behavioral health settings

Obesity prevention, fitness and tobacco cessation

Public Health Infrastructure: $70 million Support state, local, and tribal public health infrastructure

Build state and local capacity to address infectious diseases

Research and Tracking: $31 million Data collection and analysis

Strengthen CDC’s Community Guide & the Task Force on Community Preventive Services

Improve transparency & public involvement in the Clinical Preventive Services Task Force

Public Health Training: $23 million Expand CDC’s public health workforce programs & training centers

24

2010 Expenditures

Prevention & Public Health Fund

$250 million to boost supply of primary care providers:

Creating additional primary care residency slots: $168 million Training more than 500 new primary care physicians by 2015

Supporting physician assistant training in primary care: $32 million Supporting the development of more than 600 new physician assistants

Encouraging students to pursue full-time nursing careers: $30 million Help over 600 nursing students attend school full-time

Establishing new nurse practitioner - led clinics: $15 million Operation of 10 nurse-managed health clinics & assist with training nurse

practitioners.

Encouraging states to plan for and address health professional workforce needs: $5 million Help states plan and implement innovative strategies to expand their primary

care workforce by 10 - 25 percent over ten years

2011 Expenditure Plan Pending

25

Nutrition Labeling of

Standard Menu Items

Established nutrition labeling of standard menu items at chain restaurants (20 or more locations doing business under the same name).

Disclosing calories on menu boards and in a written form;

Additional information pertaining to total calories and calories from fat, amounts of fat and saturated fat, cholesterol, sodium, total and complex carbohydrates, sugars, dietary fiber, and protein must be available on request.

26

National Workforce Commission

Establishes a National Health Care Workforce Commission to serve as a national resource to: Determine whether the demand for health care workers is being met;

Identify barriers to coordination and encourage innovation;

Disseminate information on retention practices for health care professionals and;

Shall review current and projected health care workforce supply and demand and make recommendations regarding healthcare workforce priorities, goals and policies.

The Commission shall communicate and coordinate with a variety of federal agencies and departments……. Public health professionals are included in the definition of health care workforce and the definition of health professionals. Public health workforce capacity is also included in the high priority areas list.

27

Public Health Worker

Recruitment & Retention

Establish a public health workforce loan repayment program to eliminate critical public health workforce shortages in Federal, State, local and tribal public health agencies.

Individuals receiving assistance must work at least three years in these agencies. In FY 2010, $195 million is authorized to be appropriated for this program, and such sums as necessary for FY 2011 - 2015.

Also creates allied health workforce recruitment and retention programs.

Authorizes the Secretary to make grants or enter into contracts to award scholarships to mid-career public health and allied health professionals to enroll in degree or professional training programs. Authorizes $60 million for these programs in FY 2010 and such sums as necessary for FY 2011 - 2015.

Not funded to date

28

Public Health Systems

Research

Authorizes CDC to fund research in the area of public

health services and systems. Research shall:

Examine best practices relating to prevention, with a particular

focus on high priority areas identified from in the National

Prevention Strategy or Healthy People 2020

Analyzing the translation of interventions to real-world settings

Identify effective strategies for organizing, financing or

delivering public health services in real world community

settings, including comparing State and local health

department structures and systems in terms of effectiveness

and cost.

29

Eliminating Health Disparities

Requires HHS to ensure that any ongoing or federally conducted or supported health care or public health program, activity, or survey collects and reports, to the extent practicable, data on race, ethnicity, gender, geographic location, socioeconomic status, language and disability status

Gather data at the smallest geographic level.

The Secretary shall analyze the data to detect and monitor trends in health disparities and disseminate this information to relevant Federal agencies

Codifies Offices of Minority Health in HHS agencies

WEB Dubois

30

NATIONAL STRATEGY FOR QUALITY

IMPROVEMENT IN HEALTH CARE

The Secretary, shall establish a national strategy to improve the delivery of health care services, patient health outcomes, and population health. Initial strategy to Congress due January 1, 2011

In the development and implementation of quality measures the consensus-based entity (NQF) must convene and solicit input from multiple stakeholder groups (i.e., voluntary collaborative of affected organizations, such as HQA) regarding the: Selection of measures (NQF-endorsed or proposed by the Secretary)

Identification of national priorities for quality improvement

NQF is engaging public health community in this effort

31

Data: The Key To Accountability

Public health has the

lead role to oversee

accountability of the

system

Must be accountable

Must be regulators

Must be change agents

Engage in HIT system

development

32

2010 State Health RankingsUnited Health Care, APHA, PFP

32

RAN

K

STATE

18 Wisconsin

19 Wyoming

20 South Dakota

21 Maryland

22 Virginia

23 Kansas

24 New York

25 Montana

26 California

27 Pennsylvania

28 Alaska

29 Illinois

30 Michigan

31 Arizona

32 Delaware

33 New Mexico

34 Ohio

RAN

KSTATE

1 Vermont

2 Massachusetts

3 New Hampshire

4 Connecticut

5 Hawaii

6 Minnesota

7 Utah

8 Maine

9 Idaho

10 Rhode Island

11 Nebraska

12 Washington

13 Colorado

14 Iowa

15 Oregon

16 North Dakota

17 New Jersey

RAN

K

STATE

35 North Carolina

36 Georgia

37 Florida

38 Indiana

39 Missouri

40 Texas

41 South Carolina

42 Tennessee

43 West Virginia

44 Kentucky

45 Alabama

46 Oklahoma

47 Nevada

48 Arkansas

49 Louisiana

50 Mississippi

Address accountability

for health outcomes

33

Some Want To Go Backward

There will be several attempts to dismantle the new health reform law

The Prevention and Public Health Fund has already been attacked.

There are more plans to use the Prevention and Public Health Fund to pay for other programs.

Funding from the Prevention and Public Health Fund is being put to use in communities across the country to address key public health issues: Tobacco use

Reduce obesity

Encourage better nutrition

Increase physical activity

Strengthen state, territorial, tribal and local public health infrastructure

We must be prepared to respond to advocate

for the health of our communities!

34

North Carolinians Will

Lose Prevention Benefits

Prevention Benefit New insurance plans would no

longer be required to cover recommended preventive services

They will lose the guarantee of the right to choose any available primary care provider in the network or OB-GYN without a referral

1.4 million seniors in North Carolina with Medicare would be forced to pay a co-pay to receive important preventive services, like mammograms and colonoscopies

1.4 million seniors with Medicare in North Carolinawould lose annual check-up visit

Source: White House

35

Critical Consumer Protections Lost

37,300 young adults would lose their insurance coverage through their parents‟ health plans

Insurers would no longer be required to spend at least 80 to 85 percent of premium dollars on health care (Affects 4.6 million North Carolinas with private coverage)

More than 4.6 million residents of North Carolina with private insurance coverage would again have lifetime limits

Insurance companies would once again be allowed to do rescissions & cut off someone‟s coverage unexpectedly when they are in an accident or become sick because of a simple mistake on an application (Effects 499,000 people)

Source: White House

36

North Carolina Would Lose Funding

Plan for a Health

Insurance Exchange

Support a Consumer

Assistance Program

Crack Down On

Unreasonable

Premium Increases

Source: White House

37

Predictions For Year 2015

Legal & legislative efforts fail directlybut slow down progress of implementation indirectly

Medical care system changes that focus on chronic disease are slowly adopted

Prevention & wellness components of ACA are implemented but slowly & unevenly

Public health funding levels off

• Chronic disease rates continue rapid increase

• Health care costs savings are not optimized

38

We Need To Look Forward

Take a long view

Health is a national asset

& investment to be

protected

Community & Clinical

prevention are key factors

in a well structured health

system

Governmental as well as

nongovernmental health

agencies must be robust

& sustainable “The best way to predict the future is to invent it”……

Alan Kay, 1971

39

What Ever Happens: Public Health

Still Has Core Responsibilities

MARK YOUR CALENDARS NOW!

JUNE 23-25, 2011

YOU DON’T WANT TO MISS THIS VERY

IMPORTANT & INFORMATIVE MEETING

Detailed Agenda, Speakers, Hotel

and Registration Information

Available in January 2011

www.apha.org/midyear

””Protect, Prevent, Live Well”

Georges C. Benjamin, MD, FACP, FACEP(E), FNAPA, Hon FRSPH

Executive Director

American Public Health Association

WWW.APHA.ORG

”Protect, Prevent, Live Well”