The third in a four-part series on “Obamacare,” this latest installment discusses the Affordable Care Act’s emphasis on public health that builds a system focused on wellness and prevention rather than sickness and disease. Part two of this installment, to be published in our October issue, will continue this discussion.
Chronic diseases and conditions such as heart disease, cancer, strokes and diabetes are responsible for seven of 10 American deaths each year and 75 percent of the nation’s health spending. Many behaviors lead to poor health and these chronic conditions—behaviors such as tobacco use, poor diet, physical inactivity and alcohol abuse. Such is the case of today’s American health care system—the need to address diseases and conditions that, in many cases, are preventable. Little-recognized provisions of the Affordable Care Act seek to change the health care system by placing a greater emphasis on health and by promoting strategies that will help create healthier people and healthier communities.
Affordable Care Act and the Emphasis on Health
In general, the Affordable Care Act seeks to fully implement the National Quality Strategy developed by the U.S. Department of Health and Human Services. The National Quality Strategy has three primary aims:
- Better care—improving the overall quality of health care and making health care more patient-centered
- Healthy people and communities—improving the health of the U.S. population by supporting proven interventions to address behavioral, social and environmental determinants of health
- Affordable care—reducing the cost of quality health care for individuals, families, employers and the government
In addition, the National Quality Strategy has several priorities that the Affordable Care Act specifically addresses. According to Dr. Keith Mueller of the University of Iowa College of Public Health, those priorities are:
- Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease
- Working with communities to promote the wide use of best practices to enable healthy living
Taken together, the connection between the Affordable Care Act and the aims and priorities of the National Quality Strategy will result in an unprecedented emphasis on public health and prevention. In other words, seeking to turn the current “sick care system” into a true “health care system.”
On June 16, 2011, the Obama administration released the National Prevention and Health Promotion Strategy, a plan that was called for in the Affordable Care Act. This plan is viewed as a roadmap that will help public entities and the private sector to partner to build a system that focuses on wellness and prevention rather than sickness and disease, according to Health and Human Services Secretary Kathleen Sebelius. The plan has four “strategic directions”:
- Building healthy and safe community environments
- Expanding quality preventive services in both clinical and community settings
- Empowering people to make healthy choices
- Eliminating health disparities
Prevention and Health Insurance Reforms
The Affordable Care Act contains several provisions reforming how private and public health insurance plans handle preventive care and procedures. Among them are:
- Beginning in 2010, the Affordable Care Act requires new health plans (those plans joined after March 23, 2010) to cover recommended preventive services at no charge by exempting those benefits from deductibles, co-pays and other cost-sharing requirements. Preventive services include vaccinations, annual physicals, screenings for common conditions and well-baby and well-child visits.
- In 2011 co-pays and other cost-sharing for preventive services are eliminated in Medicare. In addition, Section 4103 of the Affordable Care Act adds a covered annual wellness visit for Medicare beneficiaries with necessary advice and referrals. Some physicians believe the Medicare wellness screenings under this provision do not provide enough information to catch and treat health problems at an early stage. Other physicians believe the new screening regulations are worthwhile in testing for health and safety issues. In addition, since Jan. 1, 2011, only about 780,000 Medicare patients (of a national total of 46 million) have received the new wellness service. However, some health policy experts have suggested that in general the impact and use of preventive services—including those associated with Medicare—will grow over time.
- Beginning in 2014, health insurance plans sold through the health insurance marketplaces, or Exchanges, must provide minimum essential benefits or coverage. The U.S. Department of Health and Human Services will decide the details of what benefits are required. But the general categories contained in the Affordable Care Act include preventive and wellness services and chronic disease management.
- The Affordable Care Act encourages states to improve coverage and access to recommended preventive services and immunizations to Medicaid beneficiaries. States are required to provide Medicaid coverage for tobacco-cessation services for pregnant women without cost-sharing. States that offer Medicaid coverage for common preventive services without cost-sharing will receive a 1 percentage point bonus in their federal Medicaid assistance payments. Incentives will be offered to Medicaid beneficiaries who successfully complete healthy lifestyle programs.
Prevention and Public Health Fund
Title IV, Subtitle A of the Affordable Care Act creates the Prevention and Public Health Fund, a $15 billion fund over 10 years to expand investment in prevention and public health programs. The goal of the fund is to shift from treating diseases to preventing illness.
The concern about future costs of chronic diseases is one of the foundations behind the fund. It is estimated that two-thirds of the increase in health care spending between 1987 and 2000 was due to increased prevalence of chronic diseases. Greater investments in community-based prevention interventions are seen as a cost-effective method to bend the cost curve. The return on investment for community-based prevention interventions is estimated at six dollars for every dollar invested.
As stated by a group of national public health organizations in an April 1, 2011, letter to President Obama, “millions of dollars in mandatory funding are spent each year via the Medicare, Medicaid and other federal health care programs to pay for health care services once patients develop an acute illness, injury or chronic disease …” Add in the costs expended through private health insurance and it becomes billions of dollars. Until the fund was created there was no equivalent funding for “efforts to promote wellness, prevent disease, and protect against public health or bioterror emergencies.”
According to Alice Dembner of Community Catalyst, expanding prevention initiatives is “one-third of the package needed to control health care spending,” in addition to reducing waste and bad care in Medicaid and Medicare, and cutting prices and high administrative costs in the private sector. Other experts see preventive services as “cost-effective” rather than cost-saving; the benefits of preventive services in improved health outcomes outweigh the costs of the services. In any event, investments in prevention and public health are an expression of common sense public policy—if we as a society wish to reduce health care costs, individuals, families and communities must be healthier.
One of the first uses of the fund was to dedicate $250 million from July 2010 to June 2011 to support the training and development of primary care professionals, a major deficiency and critical need in rural areas and inner cities.
In April 2011 the U.S. Department of Health and Human Services allocated an additional $250 million from the fund for prevention and public health initiatives at the federal, state and local levels. Priority areas include:
Community and Clinical Prevention
- Putting Prevention to Work—Supporting federal, state and community initiatives to employ evidence-based strategies
- Primary and Behavioral Health Integration—Assist communities with coordination of primary care services in mental and behavioral health settings
- Obesity Prevention and Fitness—Support activities to improve nutrition and increase physical activity to promote healthy lifestyles and reduce obesity-related conditions and costs
- Tobacco Cessation—Implement anti-tobacco media campaigns to provide information on tobacco cessation services
Public Health Infrastructure
- Public Health Infrastructure—Support state, local and tribal public health infrastructure to advance health promotion and disease prevention
- Epidemiology and Laboratory Capacity Grants—Grants to build state and local capacity to prevent, detect and respond to infectious disease outbreaks
Public Health Training
- Public Health Workforce—Expands the Center for Disease Control (CDC) public health workforce programs
- Public Health Training Centers—Supports the training of public health providers to and improves the access and quality of health services in medically underserved communities, including many rural areas
On April 13, 2011, the U.S. House of Representatives approved H.R. 1217 that would have repealed the Prevention and Public Health Fund. The bill has not been considered in the U.S. Senate, and President Obama has indicated he would veto any legislation repealing the fund.