The Future of Public Health: Improving Health Impact

1. The Future of Public Health: Improving Health Impact “The Affordable Care Act Implementation in a Changing Environment” National Indian Health Board Washington, DC April 20, 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 • Covers 32 million people • 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 • Tribes 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. 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

9. 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.

10. 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)

11. 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

12. Impact Of Coverage On The CDCBreast & 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

13. 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

14. 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

15. National Prevention, Health Promotion & Public Health Council Recommended Strategies For Effective Action • Policy • Systems Change • Environment. • Communications and Media • Program and Service Delivery

16. Diseases Cardiovascular disease Cancer Lower respiratory disease Unintentional injury Behavioral health Behaviors Tobacco use Nutrition Physical inactivity Early alcohol use/ abuse Council’s Initial Areas of Focus Seeking Public Input For Next Report

17. 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.

18. 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.

19. Jungle Gym’s Make Healthy Kids

20. 2010 ExpendituresPrevention & 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 & HRSA training centers

21. 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

22. 2011 Second Year ($750 Million)ACA Prevention & Wellness Fund • Community Prevention ($298 million): Promote health & wellness in local communities, including efforts to prevent & reduce tobacco use; improve nutrition & increase physical activity; and coordinate & focus efforts to prevent chronic diseases. • Clinical Prevention ($182 million): Improve access to preventive care, including increasing awareness of the new prevention benefits provided under the new health care law. Increase availability & use of immunizations, and help integrate behavioral health services into primary care. • Public Health Infrastructure ($137 million): Help state and local health departments meet 21st century challenges, including investments in information technology & training for the public health workforce to detect & respond to infectious diseases and other health threats. • Research and Tracking ($133 million): Collect data to monitor the impact of the Affordable Care Act on the health of Americans & identify and disseminate evidence-based recommendations on important public health challenges.  

23. 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.

24. 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.

25. 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

26. 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.

27. 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

28. 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

29. National Board of Public Health ExaminersA New Tool To Improve Individual Competency • Voluntary certification exam • Graduate degree from CEPH accredited school / program • Ensure that students and graduates from schools and programs of public health accredited by the Council on Education of Public Health (CEPH) have mastered the knowledge and skills relevant to contemporary public health practice We give anyone a badge?

30. Public Health Accreditation Board • Voluntary accreditation system in development: Several workgroups • Standards & measures • Research & Evaluation • Equivalency • Goal is to improve the functioning of governmental public health departments • www.phaboard.org Too many health departments w/o full capacity

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 Address accountability for health outcomes 33

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. Predictions For Year 2015 • Legal & legislative efforts fail directly but 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

35. 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

36. What Ever Happens: Public Health Still Has Core Responsibilities

37. 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”

38. Georges C. Benjamin, MD, FACP, FACEP(E), FNAPA, Hon FRSPH Executive Director American Public Health Association WWW.APHA.ORG ”Protect, Prevent, Live Well”