 Research Insights Public Health’s Role in a Post-ACA World Summary Perhaps the most well-known aspect of the ACA is its influence on The Patient Protection and Affordable Care Act (ACA) contains insurance coverage. The inaugural open enrollment period— the several provisions which may alter the scope and practice of public period in which eligible individuals can enroll in a Qualified Health health. As a result, governmental public health departments must Plan in the Marketplace3—closed March 31, 2014. Most estimates in- evolve in order to accommodate the new health landscape and dicate that, to date, more than 8 million people have gained coverage, changing demands on the system.1 Three governmental public and the upcoming 2015 enrollment period is expected to secure even health departments—Massachusetts, San Diego, Vermont—are more coverage.4,5 The law also provides states with additional federal taking unique approaches to this opportunity for public health to funding to expand their Medicaid programs, in which individuals can innovate in the wake of health systems change. enroll at any time given that they meet the requirements.6 Introduction Despite these increases in health insurance coverage, access issues The ACA was signed into law in 2010 with the goal of improving still remain. Furthermore, it is unclear how coverage expansion will the quality and affordability of health insurance as well as increas- affect changes in the delivery of public health services. Title IV of the ing access to primary care and preventive services. The ACA ad- ACA, “Prevention of Chronic Disease and Improving Public Health,” dresses population health in four ways:2 outlined new funding mechanisms for public health and established standards for prevention activities.7 One such funding mechanism, 1.Expands insurance coverage (e.g., individual mandate, Medicaid the Prevention and Public Health Fund, herein referred to as “the expansions, coverage up to age 26); Fund,” was established to provide incentives for providers to invest 2.Improves quality of care (e.g., National Strategy for Quality Im- in public health and prevention. The establishment of the Fund is provement); considered one of the most substantial efforts in recent years to fund 3.Enhances prevention and promotion measures (e.g., expansion public health infrastructure. Specifically, the Fund supports scientific of primary health care training); prevention programs and allows public health departments to address 4.Promotes community- and population-based activities (e.g., workforce and sustainability issues, e.g., public health training centers. Prevention and Public Health Fund). In addition, in 2013, the Fund allocated millions to federal agencies, as depicted in the table below . The table includes the expected amounts, per the 2014 fiscal year budget. Genesis of this brief: AcademyHealth’s Annual Research Meeting 2014 As part of its efforts to support evidence-based public health and share policy innovations, the Robert Wood Johnson Foundation sponsored an invited panel at the 2014 AcademyHealth Annual Research Meeting to explore how governmental public health may change following imple- mentation of the Patient Protection and Affordable Care Act (ACA). The panel, “Public Health’s Role in a Post-ACA World,” featured presenta- tions from Thomas Land, Ph.D., Office of Health Information Policy and Informatics at the Massachusetts Department of Public Health; Wilma Wooten, M.D., M.P.H., County of San Diego Health and Human Services Agency; and Jenney Samuelson, Blueprint for Health, Department of Vermont Health Access. Alefiyah Mesiwala, M.D., M.P.H., Center for Medicare and Medicaid Innovation, moderated the panel. This brief sum- marizes that discussion. Public Health’s Role in a Post-ACA World Prevention and Public Health Fund provision of STD counseling and partner notification increased from Spending by Agency 2010 (79 percent) to 2012 (85 percent), the percentage of state health (dollars in millions) agencies directly performing all other services remained the same FY 2013 FY 2014 or decreased from 2010 to 2012, with the overall trend decreasing.”14 Final Allocation Requested Allocation Beyond the ASTHO profile, early findings from the field of Public Health Services and Systems Research (PHSSR) support this trend AHRQ 6.465 7.000 and suggest that, as a result, agencies are looking to either develop CDC 462.916 831.00 revenue streams by billing for those services, or are turning away CMS 453.803 0.000 from the provision of health care altogether .15, 16, 17 HRSA 1.847 0.000 As the provision of clinical services largely transitions out of public SAMHSA 14.733 62.000 health’s domain,18 there remains a crucial leadership role for govern- ACL 9.236 27.700 mental agencies—that of chief health strategists. The Public Health Leadership Forum, in partnership with RESOLVE, released a report, Subtotal, all GDM 0.000 0.000 “The High Achieving Governmental Health Department in 2020 as Sequestered funds 51.000 72.000 the Community Chief Health Strategist” in order to provide direction Total, all activities 1,000.000 1,000.000 in the face of this ensuing change. The forward-thinking document Final funding amounts for 2015 are not yet known. is a call to action to the public health community; it boldly cautions, Modified from Trust for America’s Health. Prevention and Public Health Fund. [Internet]. 2014 [updated “Unless [public health] recognize[s] the new circumstances and 2014 Jan 22; cited 2014 Sept 1]. Available from: http://healthyamericans.org/health-issues/wp- content/uploads/2014/01/PPH-2010-2014-1-22-14.pdf adapt[s] accordingly, public health will not just be ineffective, it runs the risk of becoming obsolete.” These provisions—and the law itself—have the potential to shift the health care system into one that supports health and wellness as The Forum calls for public health leaders to leverage their knowl- well as treats the sick. For example, in 2014, the Centers for Dis- edge of population health and prevention in order to link clinical ease Control and Prevention (CDC) was allocated $146 million in care providers with individuals, to provide prevention guidance and Community Transformation Grants, with the purpose of funding expertise, and, in some cases, to continue their safety-net activities, community-level prevention programs.8 More recently, on Septem- e.g., HIV services.19 The report suggests six key practices for high- ber 25, 2014, the CDC announced an additional $211 million for 193 achieving public health departments (see text box, Key Practices of the awards for states, large and small cities and counties, tribes and tribal Chief Health Strategists of the Future). organizations, and national and community organizations to focus on populations hardest hit by chronic diseases.9 This brief examines three innovative approaches to public health transformation and recognizes challenges that still remain. Despite this significant investment, the Fund is not without contro- versy. Initial federal legislation proposed that the Fund would receive Key Practices of the upwards of $15 billion in investment—$2 billion per year. Yet, the Chief Health Strategists of the Future government has continued to slash allocations for the Fund due to a 1. Adopt and adapt strategies to combat the evolving leading causes rising national budget deficit, the enactment of sequestration, reallo- of illness, injury, and premature death. cation of funds to support the federal health insurance exchange and 2. Develop strategies for promoting health and well-being that work Medicare’s “doc fix,” and ultimately, a criticism of the Fund as waste.10 most effectively for communities of today and tomorrow. 3. Chief health strategists will identify, analyze and distribute Public health, historically, has been “a regulator (i.e., emergency pre- information from new, big, and real time data sources. paredness, disease outbreak), ‘gap-filler,’ and, especially in southern 4. Build a more integrated, effective health system through states, a provider;” 11 many governmental public health departments collaboration between clinical care and public health. have traditionally either provided services to the underserved or 5. Collaborate with a broad array of allies- including those at the contracted with private organizations to do so, allowing them to fill neighborhood-level and the non-health sectors-to build healthier and more vital communities. gaps where services were previously underprovided.12 However, with coverage expansion, fewer patients will likely rely on governmental 6. Replace outdated organization practices with state-of-the-art business, accountability, and financing systems. public health departments for subsidized clinical services.13 The Source: Public Health Leadership Forum. The high achieving governmental health most recent Association of State and Territorial Health Officials department in 2020 as the community chief health strategist. Washington, DC: RESOLVE Inc.; 2014. (ASTHO) profile (2014) further illustrated this movement—“While 2 Public Health’s Role in a Post-ACA World Case Study: Linking Clinical and Community: The Massachusetts Prevention and Wellness Trust Funding Allocation for Prevention and Wellness Trust Massachusetts’ health reform was first passed in 2006 and then • million in trust for 4 years; $57 revisited in 2012,20 when the legislation created the Prevention and • requirement for spending equal amounts annually; No • least 75% must be spent on grantee awards; At Wellness Trust as a mechanism for controlling health care costs. • more than 10% on worksite wellness programs; No Chapter 224 of Massachusetts’ health cost containment bill estab- • more than 15% on administration through Massachusetts No lished a $60 million trust for the Department of Public Health to Department of Public Health. provide grants to local communities to address the costliest and Source: Land, T. “Linking Clinical and Community: The Massachusetts Prevention and Wellness Trust.” Presentation at the AcademyHealth Annual Research Meeting. San Diego, most preventable health conditions and associated risk factors.21 CA, June 9, 2014. Recipients of funding were required to support clinical and com- pressing chronic diseases. As solutions are sought for better integrating munity-based interventions and deliver a positive return-on-invest- public health and health care during this time of health system trans- ment (ROI) in a 3.5 year period. Herein lies a great challenge for formation, lessons are sure to arise from the Massachusetts Depart- those implementing the Trust: public health benefits are generally ment of Public Health’s experience with the Trust. dispersed or delayed, and because they occur at the population level versus within individuals, measuring ROI for public health invest- Case Study: Accountable Care Community: Live ments is methodologically complex.22 Definitional issues around Well San Diego value further complicate the evaluation of public health interven- The Health and Human Services Agency of San Diego County is tions;23 however, the statute stipulates that additional Trust funding one of five business groups of the county government. The Agency is dependent on this evaluation. provides a broad range of health and social services, promoting wellness, self-sufficiency, and a better quality of life for all individu- The statute established that grantees had to successfully do one or als and families in San Diego County. The Agency integrates health more of the following: reduce rates of preventable health condi- and social services through a unified service-delivery system;24 it tions, increase healthy behaviors through evidence-based interven- does not conduct primary care. The elimination of primary care ser- tions, increase adoption of workplace-based wellness programs, vice competition has allowed the Agency to take a holistic approach address health disparities and further develop the evidence base to population health. through research, evaluation and continuous quality improvement. The Department partnered with the Statutory Advisory Board, The Live Well San Diego (LWSD) initiative uses a “10-5-1” model schools of public health, the CDC, and Social Impact Bonds, to to achieve an “accountable care community.” The model uses 10 determine which interventions have the potential for the most measures in five areas of influence to support their one vision of effective implementation, largest clinical impact, greatest ROI and overall health. greatest sustainability. They contract with outside evaluators to assist grantees with demonstrating ROI and also provide consultation on The 10 measures are depicted in the chart. The five areas of influ- opportunities for additional investment by outside sources. ence include health, knowledge, standard of living, community, and social wellbeing. An exemplary program under the LWSD umbrella The Trust sought to make outcomes data available to all grantees is the Community-based Care Transitions Program (CCTP), a simultaneously. The statute requires that all grantees use a bi- CMMI-funded initiative which blends inpatient health care and directional e-referral program funded by the Center for Medicare social service care.25 The goal of CCTP was to improve transitions of and Medicaid Innovation (CMMI). The requirement of e-referrals 21,340 Medicare fee-for-service patients from inpatient hospital set- allows for the provision of quantitative data and therefore a strong tings to home/care settings. Utilizing the LWSD framework, CCTP foundation for program comparison. This critical linkage serves sought to improve the quality of care and reduce readmission for as a measurement tool as well as a quality improvement monitor. high-risk beneficiaries. The initial goal was to reduce readmission Through electronic links, grantees can define referral elements, by 20 percent in two years. It was imperative that measurable sav- export data and reports, and also foster continuous quality improve- ings to the Medicare program were documented. CCTP consisted of ment. This innovative requirement has served to join the discon- several partnerships among four health care systems in 13 hospitals nected municipalities in Massachusetts, all of which have separate in San Diego. As of December 31, 2013, CCTP had served 8,506 pa- boards of health, resource pools, and populations. tients. Readmissions were reduced from 18.6 percent to 8.5 percent that year, on track with their goal.26 The comprehensive coordina- The Department of Health awarded nine grants—collaborative initia- tion among sectors, led by the County Health and Human Services tives consisting of municipalities, health plans, clinicians, and commu- Agency was instrumental in reducing readmission. nity-based organizations, all working towards ameliorating the most 3 Public Health’s Role in a Post-ACA World Furthermore, the model centers on the incorporation of a leader- Top 10 Live Well San Diego Indicators ship network. The program boasts a leader in every aspect of care. •Life expectancy Leaders of respective program areas share best practices, collabora- •Quality of life tively determine next steps, and discuss allocation of resources. This •Education degree of communication and collaboration has allowed Blueprint •Unemployment rate •Income to work efficiently across geographic regions and specialties. •Security •Physical environment Blueprint is a population-focused program, with a mission to pro- •Built environment vide preventive care across all practices. Blueprint has established •Vulnerable populations new connections and redesigned service delivery. Specifically, it •Community involvement provides services not covered by traditional health plans and largely Source: Wooten, W. “Accountable Care Community: Advancing Population Health through Live Well San Diego.” Presentation at the AcademyHealth Annual Research Meeting. San focuses on prevention e.g. obesity prevention programs. Addition- Diego, CA, June 9, 2014. ally, Blueprint has shifted attention to social determinants of health (i.e. safe housing, education, employment, access to health care etc.) Underpinning the model are four strategies: building better service and works to alleviate disparities by incorporating social services delivery systems, supporting positive and healthy choices, pursu- such as housing, food and transportation into its model. The public ing policy and environmental changes, and improving the culture health department is an integral partner in designing and deploy- within the county government. These strategies support three over- ing these programs. all components or pillars of the initiative – building better health, living safely, and thriving. All LWSD programs operate under Blueprint’s most recent annual report28 (2013) has illustrated one of these three pillars. As San Diego strives to achieve a solid, tremendous cost savings for the state—an overall investment of $5 comprehensive approach to improving population health, the three million resulted in an $81 million saving. Data show that PCMH pillars of LWSD may provide examples for other health agencies in and CHT patients had improved healthcare patterns and reduced this post-ACA era. medical expenditures per capita. They were also better connected to non-medical support services. Case Study: Vermont Blueprint for Health: Community System of Health The Vermont Public Health department has been integral in the oversight of these services. Their expertise has positioned them to Blueprint for Health (Blueprint) is Vermont’s state-led initiative to connect various stakeholders and strengthen the Blueprint overall. reform health care delivery and affordability. Blueprint was estab- lished in 2006 in Act 191 of Vermont’s Health Care Affordability Conclusion Act. Its overall goal is to ensure that all Vermont citizens have ac- According to a recent Urban Institute report, the ACA and con- cess to, and coverage for, high-quality, holistic health care. Blueprint sequent Medicaid expansion will likely decrease the number of utilizes a highly coordinated approach, including partnerships with uninsured by 57 percent.29 Yet, gaps in coverage will still remain as providers, the health department, and community health workers, the law moves forward and enrollment periods continue. Specifi- in order to build an integrated health care system. The program cally, states that choose not to expand Medicaid will not see as began as a multi-stakeholder working group focused on chronic large of a coverage gain. Additionally, and regardless of Medicaid disease. Utilizing the Chronic Care Model, 27 the group’s initial expansion, undocumented immigrants will remain one of the larg- framework evolved into the current program, a model of compre- est uninsured groups.30 Per tradition, especially in the near term, it hensive health delivery. is expected that public health will continue to serve as a safety-net provider for these underserved individuals.31 The model incorporates advanced primary care in the form of Patient-Centered Medical Homes (PCMH) and multi-disciplinary In addition to this ACA-driven shift of clinical preventive services support services in the form of Community Health Teams (CHT). (from the public health to the health care system), other condi- Also integral to the framework is a network of self-management tions also call for governmental public health department trans- support programs, statewide data systems, multi-insurer payment formation. These include changing population health needs (e.g., reform, health information infrastructure, evaluating and reporting increased prevalence of chronic disease), changing demographics systems and learning health system activities. All major insurers in (e.g., aging population), and the information and data revolution.32 Vermont participate in payment reforms designed to support the PCMH and CHT operations. 4 Public Health’s Role in a Post-ACA World Innovations in system transformation are happening in Massachu- Suggested Citation setts, San Diego, and Vermont, where governmental public health Robbio D and Papa K. “Research Insights: Public Health’s Role in is acting as a critical partner in prevention and care delivery. The the Post-ACA World,” AcademyHealth. October 2014. Massachusetts Department of Public Health offers a new funding mechanism to support well-planned and cost-effective community- Endnotes level intervention programs. These programs are reducing the 1. Public Health Leadership Forum. The high achieving governmental health incidence of chronic disease and providing a critical link between department in 2020 as the community chief health strategist. Washington, DC: RESOLVE Inc.; 2014. the community and clinic. 2. Stoto MA. Population health in the Affordable Care Act era. Washington, DC: AcademyHealth; February 2013. 3. U.S. Centers for Medicare & Medicaid Services. Open enrollment period. San Diego’s approach to health is multi-sectoral; the scale of the [Internet]. 2014. Available from: https://www.healthcare.gov/glossary/open- program and ability to connect individuals to several resources enrollment-period/ 4. Sommers BD, Musco T, Finegold L, Gunja MZ, Burke, A, McDowell AM. across multiple sectors showcases the potential for governmental Health reform and changes in health insurance coverage in 2014. NJEM. 2014 public health to create wholly healthy communities through public July 23; ePub. 5. Volk J, Corlette S, Ahn S, Brooks T. Report from the first year of navigator and private partnerships. technical assistance project: lessons learned and recommendations for the next year of enrollment. Washington, DC: Georgetown University Health Policy Institute;2014. Vermont’s Blueprint program is another example of the ability of 6. U.S. Centers for Medicare & Medicaid Services. Medicaid expansion and what governmental public health to act as an instrumental partner and it means for you. [Internet]. 2014. Available from: https://www.healthcare. gov/what-if-my-state-is-not-expanding-medicaid/ developer of community wellness initiatives. The intentional inclu- 7. Patient Protection and Affordable Care Act of 2010, IV U.S.C. § 4301 sion of leadership teams and community health workers woven into 8. Trust for America’s Health. Prevention and Public Health Fund. [Internet]. 2014 [updated 2014 Jan 22; cited 2014 Sept 1]. Available from: http:// standard health care delivery is helping the state prioritize preven- healthyamericans.org/health-issues/wp-content/uploads/2014/01/PPH-2010- tion of, rather than treatment for, disease and disability. 2014-1-22-14.pdf 9. Centers for Disease Control and Prevention. [Internet]. 2014 [updated Sept 25; cited 2014 Oct 3]. Available from: http://www.cdc.gov/chronicdisease/ As the provision of preventive services shifts from the public about/2014-foa-awards.htm health to health care sector, governmental public health depart- 10. Kliff S. The incredible shrinking prevention fund. Washington Post. 2013 Apr 19. [Internet] Available here: http://www.washingtonpost.com/blogs/ ments have an opportunity to take on a new role. At this turning wonkblog/wp/2013/04/19/the-incredible-shrinking-prevention-fund/ point, some public health departments have shown willingness to 11. AcademyHealth. The evolution of public health. 2012 Mar 14 [Internet]. Available from: http://blog.academyhealth.org/the-evolution-of-public-health/ critically assess this opportunity, and evolve in the face of change. 12. Bovbjerg RR, Ormond BA, Waidmann, TA. What direction for public health These case studies demonstrate that public health departments under the Affordable Care Act? Washington, DC: Urban Institute; 2011. 13. Association of State and Territorial Health Officials. ASTHO Profile of State can indeed be agents of change—that leadership, partnership, Public Health, Volume Three. Washington, DC: Association of State and and innovation are occurring in states and communities, and that Territorial Health Officials. 2014. 14. Shaw FE, Asomugha CN, Conway PH, Rein AS. The Patient Protection and public health’s participation is crucial to the advancement of a Affordable Care Act: opportunities for prevention and public health. ePub: culture of health in America. Lancet; 2014. 15. Kilgus CD, Redmon GS. Enabling reimbursement to health departments for immunization services. J Public Health Manag Pract 2014; 20(4):453-5. About the Authors 16. Etkind P, Gehring R, Ye J, Kitlas A, Pestronk R. Local health departments and Danielle Robbio, research assistant, and Kate Papa M.P.H., director, billing for clinical services. J Public Health Management Practice. 2014;20(4): 456-458. staff AcademyHealth’s public and population health program. 17. Jacobson P, Wasserman J, Wu H, Lauer JR. Public health entrepreneurship: disruptive change to public health? Am J Public Health. Forthcoming 2015. 18. Ibid About AcademyHealth 19. Public Health Leadership Forum. The high achieving governmental health AcademyHealth is a leading national organization serving the fields department in 2020 as the community chief health strategist. Washington, DC: RESOLVE Inc.; 2014. of health services and policy research and the professionals who 20. Land T. “Linking Clinical and Community: The Massachusetts Prevention produce this important work. Together, with our members, we offer and Wellness Trust.” Presentation at the AcademyHealth Annual Research Meeting. San Diego, CA, June 9, 2014. programs and services that support the development and use of rig- 21. Ibid. orous, relevant and timely evidence to increase the quality, accessi- 22. AcademyHealth. PHSR Article of the Year: How effective are public health bility, and value of health care, to reduce disparities, and to improve departments at preventing mortality? 2014 May 28 [Internet]. Available from: http://blog.academyhealth.org/phsr-article-of-the-year-how-effective-are- health. A trusted broker of information, AcademyHealth brings public-health-departments-at-preventing-mortality/ stakeholders together to address the current and future needs of an 23. Grosse S. “Return on Investment in Prevention: Value is in the Eyes of the Beholder.” Presentation at the AcademyHealth Annual Research Meeting. San evolving health system, inform health policy, and translate evidence Diego, CA, June 8, 2014. into action. For additional publications and resources, visit acad- 24. Wooten W. “Accountable Care Community: Advancing Population Health through Live Well San Diego.” Presentation at the AcademyHealth Annual emyhealth.org. Research Meeting. San Diego, CA, June 9, 2014. 5 Public Health’s Role in a Post-ACA World 25. Centers for Medicare and Medicaid Services, U.S. Department of Health 28. Vermont case study information summarized from the presentation by Jenney and Human Services. “Community-based Care Transitions Program,” n.d. Samuelson at AcademyHealth’s panel “Public Health in a Post-ACA World.” Accessed June 23, 2014, from http://innovation.cms.gov/initiatives/CCTP/. AcademyHealth Annual Research Meeting, San Diego, CA, June 9, 2014. 26. California case study information summarized from the presentation by 29. Buettgens M and Dev J. The ACA and America’s cities: fewer uninsured and Wilma Wooten at AcademyHealth’s panel “Public Health in a Post-ACA more federal dollars. Washington, DC: Urban Institute, 2014. World.” AcademyHealth Annual Research Meeting, San Diego, CA, June 9, 30. Ibid. 2014. 31. Shaw FE, Asomugha CN, Conway PH, Rein AS. The Patient Protection and 27. Samuelson J. “Vermont Blueprint for Health: Community System of Health.” Affordable Care Act: opportunities for prevention and public health. Lancet. Presentation at the AcademyHealth Annual Research Meeting. San Diego, CA, 2014 July 1; 384:75-82. June 9, 2014. 32. Public Health Leadership Forum. The high achieving governmental health department in 2020 as the community chief health strategist. Washington, DC: RESOLVE Inc.; 2014. 6