Being Accountable for the Public’s Health

1. Being Accountable for the Public’s Health Montana Public Health Association Montana Environmental Health Association September 13, 2011 Pam Aaltonen, Chairperson APHA Committee on Affiliates aaltonen@purdue.edu

2. Where Am I Going … • APHA Articulated Public Health Priorities II. APHA the Organization III. Imagine Public Health’s Future

3. Part I

4. APHA Priorities, 2011 Continuing Priorities • Public Health Funding • Health Reform • Elimination of Disparities Legislative Priorities • Appropriations and funding (HHS, CDC, HRSA, Global Health) • Protecting Affordable Care Act • Protecting Clean Air Act • Reauthorization of federal transportation programs

5. Appropriations and Funding • Assure sufficient funding for HRSA, CDC, and other HHS entities and programs • Public health small fraction of overall spending on health care … as you well know! • Stability of funding… federal, state, and local level • Montana increased per capita spending last year • What’s this year’s outlook? • Loss of positions across the country as state and county budgets impacted by economy

6. Appropriations and Funding HRSA → Montana, 2011 = $34.48 M (62 grants) Montana ranks 7th among states in HRSA funding per capita ($30.98)

7. Appropriations and Funding cont. CDC → Montana, 2010 Montana ranks 13th among states in CDC funding per capita, $25.73

8. Appropriations and Funding cont. • Like most states, your state health department relies on federal monies • State funding per capita ranks 29th; $25.51

9. Appropriations and Funding, cont. • USDHHS Funding: • discretionary funding 10% of entire budget

10. Affordable Care Act • Promise of shifting system from heavily illness oriented to prevention/wellness orientation • National Prevention, Health Promotion and Public Health Council (headed by Surgeon General) • Kaiser Family Foundation Health Reform Timeline http://healthreform.kff.org/timeline.aspx

11. Views On Health Reform Remain Divided As you may know, a health reform bill was signed into law early last year. Given what you know about the health reform law, do you have a generally favorable or generally unfavorable opinion of it? Favorable Unfavorable Don’t know/Refused ACA signed into law on March 23, 2010 2010 2011 Source: Kaiser Family Foundation Health Tracking Polls

12. Favorability of the ACA Among Key Subgroups Percent who say they have a favorable opinion of the health reform law: 2010 2011 2010 2011 2010 2011 2010 2011 BY AGE BY RACE/ETHNICITY BY INSURANCE STATUS (<65) BY INCOME Source: Kaiser Family Foundation Health Tracking Polls

13. Which Groups Will Benefit from the ACA? Do you think each of the following will be better off or worse off under the health reform law, or don’t you think it will make much difference? Better off No difference Worse off Don’t know/Refused The uninsured Lower income Americans The country as a whole Seniors, that is those ages 65 and older Your state People currently covered by Medicaid Middle class Americans You and your family Source: Kaiser Family Foundation Health Tracking Poll (conducted May 12-17, 2011)

14. If set aside political debate, most would agree that system is not functioning well CostsOutpace Inflation: • $2.4 trillion spent on health care in 2008 • > 17% of Gross Domestic Product Health Insurance CoverageProblematic: • > 50 million people are uninsured (17%) • 57 M medically disenfranchised (no usual source of health care even if have insurance) • Rising employer costs • High deductible consumer driven plans • Transparency of costs and performance DeliverySystem is Strained: • Disparities in quality and access • Challenged by medical errors, hospital readmission rates, waiting times and misuse of ER, communication issues, shortfall of primary care providers, … • Underfunded public health system

15. Projections of National Health Expenditures and Their Share of Gross Domestic Product, 2007-2018 Dollars in Billions NHE as a % of GDP: *2007 are actual data from the 2009 National Health Expenditure Accounts; 2008-2018 are projected data from the 2009 National Health Expenditure Accounts. Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/03_NationalHealthAccountsProjected.asp#TopOfPage (see Projected; NHE Historical and projections, 1965-2018, file nhe65-18.zip) and http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2007; file nhegdp07.zip).

16. National Health Expenditures per Capita, 1990-2007 Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2007; file nhegdp07.zip).

17. Health Insurance Coverage, 2009 Note: 2009 data, national trend ↓ in employer coverage, ↑ uninsured Source: Kaiser Family Foundation (2011). Statehealthfacts.org

18. Prevention in the Hospital: Avoidable Medical Errors • Institute for Science, Law and Technology study (Anderson, 2011): • 46% hospital patients at least one error • 19% error that caused serious harm • Harvard study: 18% patients injured (Landrigan, 2010) • CMS: 1 in 7 Medicare pts injured; adverse events contribute to 180,000 deaths/year (Congressional Budget Office, 2008) • Institute of Medicine (IOM) • To Err is Human: Building a Safer Health System, 1999 • 98,000 preventable deaths; cost of $29B • Advocacy for open discussion • NCHS calculation: 6th leading cause of death (ahead of diabetes) • CMS and others implemented policy to not reimburse providers for “reasonably preventable” hospital acquired conditions

19. Affordable Care Act, cont. • Prevention and Public Health Fund • $15 B, FY2010 to 2019; $2B annually thereafter • Public health programs funded thru discretionary appropriations … fluctuations • “to provide for expanded and sustained national investment in prevention and public health programs to improve health and help restrain rate of growth in private and public health care costs” • 2011: $750 M • Community Prevention … $222 M • Clinical Prevention … $182 M • Public Health Infrastructure and Training … $137 M • Research and Tracking … $133 M • 3/3 visits to Indiana legislators Summer 2011 = slush fund • Montana has received $1.62 M thru fund as of 02/11 • Public health infrastructure: $0.5 M • Primary Care Training: $1.1 M

20. Where does ACA take us? Does the public know where we fit in? We need to communicate our view of the future. Frieden, 2010, CDC Director

21. We know that many of leading causes of prematuredeath are amenable to public health action Dressler, 2007

22. You know your state’s challenges: Montana, 2010 • Overall rank = 25 • Strengths • Lower prevalence obesity (7th) • Lower incidence of infectious disease (2nd) • Low rate cardiovascular deaths (9th) • Challenges • Low immunization coverage 19 to 35 months, 85.4% (47th) • High occupational fatalities rate (47th) • High geographic disparity within the state (47th) • Cholesterol Checks (45th, 72%) • Recent Dental Visits (40th, 65.9%) • Rise in violent crimes (254 offenses per 100,000 population, 12th) America’s Health Rankings, 2011

23. Working on immunization rates • Monty, Immunization Bear with Beth Cottingham who got the Elaine Fordyce Award, 2010 • Barriers?

24. Clean Air Act • Washington, D.C., Sept. 2, 2011 — The American Public Health Association expressed its extreme disappointment today with President Obama’s delay of new national smog standards. • The draft standards, proposed by the Environmental Protection Agency, would have reduced the acceptable limits of ground-level ozone air pollution and protected Americans, especially infants, children, older adults and those with chronic diseases, from its dangerous health impacts. • “We are extremely disappointed with the delay of these lifesaving standards,” said Alan Baker, interim executive director of APHA. “We in the public health community, including EPA’s own scientific advisors, have urged stronger ozone standards to safeguard the health of Americans. The science is clear that ozone can cause asthma attacks, harm those suffering from respiratory illness, send people to the hospital and lead to death. We urge the administration to reconsider its decision and strengthen the health protections provided under the Clean Air Act based on the overwhelming scientific evidence.”

25. Transportation as a public health issue:Reauthorize Federal Transportation Programs • Giving people options about getting around = investment in public’s health • Trails, bike lanes, sidewalks, public transit • Get more people outside and active Toolkit • http://www.apha.org/advocacy/priorities/issues/transportation/Toolkit.htm

26. Part II

27. APHA • Oldest, largest and most diverse organization of public health professionals in world • Stephen Smith, age 98 at APHA’s 50th anniversary, 1921 (April 18, 1872) • Montana one of 1st four states to have affiliated with APHA … 1919, (Montana Health Association)

28. APHA Major Products • American Journal of Public Health • The Nation’s Health Newspaper • Annual Meeting • Advocacy Training • Policy Development • Books and Publications • Newsletters • Legislative Updates (Convio) • National Public Health Week • Education … learning institutes

29. APHA structure complex … • Intersectional Council • Sections, SPIGS, and Caucuses • Committee on Affiliates • Governing Council [executive board, Section and Affiliate representatives, Student Assembly] • Executive Board • Board Chairperson • President (spokesperson)

30. American Public Health Association (APHA) Strategic Map: 2010 – 2013 Be the “Go To” Organization for Public Health Improve Impact of Policy and Advocacy Provide Service to Members and the Profession to Build Capacity Use Strategic Communications to Frame Issues & Increase Impact Implement a Sustainable Business Model Create, Implement and Assess the Engagement Strategy Required for Future Success May2010

31. Affiliates • Committee on Affiliates is the major APHA constituent body representing the interests of APHA’s 53 Affiliates • All states, DC, NYC & NY, Northern and Southern CA • Link between APHA and its Affiliates to assure timely, effective communication and input • Each affiliate has an ARGC … affiliate representative to the Governing Council Lori Wier, Teton County Health Department

33. Affiliates, cont. • Affiliates pay dues to APHA ($1/member; $0.75 rebate if MPHA members also an APHA member) • Membership is being studied … what do members value? • Affiliate has a signed MOU with APHA • President and ARGC must be APHA members

34. Committee on Affiliates Purposes • Strengthen APHA/Affiliate relationship and provide effective, efficient communication • Identify and voice APHA/Affiliate concerns • Maintain working relationships within APHA committees and boards • Plan affiliate activities (with Affiliate Staff) at the APHA Annual Meeting

35. CoA Membership (n=19) • Ten regional representatives: elected by the Affiliates in the ten national regions (two year term) • Current member of APHA and his/her Affiliate • ARGC at time of becoming a member of CoA • Odd year member elections: Regions 1, 3, 5, 7, 9 • Even year member elections: Regions 2, 4, 6, 8, 10 • Six at-large representatives: appointed by APHA President/Executive Board • CoA leadership positions – 3 year commitment • Three at large – 1 from the student assembly (1 year term), 1 affiliate staff position, 1 other • Three Affiliate representatives to the Action Board: ex officio with vote (3 year staggered terms)

36. 2011 CoA Regional Representatives • Region 1 (CT, ME, MA, NH, RI, VT) – Kala Ladenheim (ME) • Region 2 (NJ, NY-C, NY-S) – Michelle Cravetz (NY) • Region 3 (DE, DC, MD, PA, VA, WV) – Debbie Hettler (DC) • Region 4 (AL, FL, GA, KY, MS, NC, SC, TN) – Mathew Dillon(FL) • Region 5 (IL, IN, MI, MN, OH, WI) – Nancy Shapiro (OH) • Region 6 (AR, LA, NM, OK, TX) – Shari Kinney (OK) • Region 7 (IA, KS, M0, NE) – David Corbin (NE) • Region 8 (CO, MT, ND, SD, UT, WY) – Jim Dale (CO) • Region 9 (AZ, CA, HI, NV) – Bernie Weintraub (CA) • Region 10 (AK, ID, OR, WA) – Regan Mattingly (AK)

37. What CoA Members Do … • Maintain communication with, and seek guidance and input from constituent states • Communicate APHA/Affiliate ideas, concerns and issues to CoA chairperson • Ensure ARGCs understand roles/responsibilities … Lori gets email from Jim Dale, Region 8 Rep • Promote intra-regional sharing of information • Facilitate identification and resolution of interstate public health problems • Attend and participate in CoA business meetings at Annual Meeting, Mid-Year Meeting, and monthly conference calls • Affiliates constitute one of the two major APHA policy making bodies (the others being representatives of APHA sections and SPIGS)

38. APHA Annual Meeting • Affiliate Day (10/29/11) • CoA Awards Reception (10/29/11) • Candidates Forum (10/31/11) • Joint CoA/ISC* meeting (10/30/11) • CoA/Student poster session (10/31/11) • CoA/Affiliate poster session (10/31/11) • CoA Scientific sessions (10/30/11) • Affiliate Executive Directors Meeting (10/30/11) • Affiliate Regional meetings (Region 5 –Great Lakes meets 10/28/11), Region 7 meeting ISC = Intersectional Council represents Sections … continue work initiated at Mid-Year Meeting in Chicago

39. 2011 Affiliate Day • AllAffiliate leadership can and are encouraged to attend • Saturday preceding the opening day of APHA’s Annual Meeting (October 29th) • Networking and discussion of current Affiliate issues • Accreditation with Kay Bender • Membership • Networking • Affiliates 101 • Reception and Awards that evening • Midyear Meeting: Chicago 2012 Charlotte, NC

40. 2011 CoA AwardsYOUR ROLE: Nominate Someone • Award for Excellence (Individual) • Outstanding Affiliate of the Year Award • Student Award (work at state affiliate level or CoA) • Students largest growing group within APHA • CoA Awards Reception / October 29 / 7:00 p.m. • Financially supported by Affiliates

41. APHA Benefits to Affiliates • Complimentary subscription to The Nation’s Health and American Journal of Public Health • APHA membership list (will distribute every January to affiliates) • President-Elects meeting at APHA headquarters • President at affiliate state convention every three years • Access to affiliate online community • Bi-annual conference call with APHA Executive Director • Affiliate grant opportunities • Technical assistance and training • Annual meeting • Affiliate Day • CoA scientific sessions • CoA poster session • CoA awards • Award for Excellence • Outstanding Affiliate of the Year • Outstanding Student of the Year • Representation at the Governing Council • Access to advocacy materials • Opportunities for networking • Advocacy for affiliates through Committee on Affiliates • National Public Health Week Materials

42. Part III

43. Imagine a Future Where • We strive to be the healthiest nation … the healthiest nation in one generation • Where practitioners • Know the health status of their entire patient panels • Who got their vaccinations, who did not and why • Whose blood pressure is controlled and whose is not • Understand the population impact • Where the public demands accountability

44. A future where we have a robust health data infrastructure • Health data tracking needs to cross all agencies & systems • HHS: CDC,AHRQ,CMS • Transportation • Housing • Commerce • CPSC • State & local agencies • Strategic investments need to be made • Vital records at state level • State based data integrity systems / people • Local public health HIT & linkages to private systems • Data security

45. Where data illuminates accountability: goals, performance, rankings • Rankings • County Health Rankings • Commonwealth Fund • America’s Health Rankings • Kids Count • AHRQ State Snapshots • Commission to build a Healthier America • Hospital Report Cards (i.e. Leapfrog, CMS) • Goals & Data • Healthy People 2020 • Federal, state & local data • National Prevention Strategy 2011

46. Where we make data driven decisions at all levels of the system … • Health leaders as change agents • Public health with a lead role to oversee accountability of the entire health system • Must have strong data system infrastructure • Data must be useful at functional levels • HIT & data systems must support transformation • Adequate resources essential

47. Where accountability is expected/essential • Must include all stakeholders • Individuals • Practitioners • Public health • Business • The general pubic • Resources allocators • Policy makers

48. Some Want To Go Backward • There have been several attempts to dismantle health reform law • The Prevention and Public Health Fund has already been attacked • There are more plans to undermine America’s core health system (Medicare & Medicaid) … better value for $$ • Yet transforming our communities through engagement at the population level is well underway

49. We can’t sit on the sidelines… • Know the facts • Engage the public • Be vocal advocates • Show results & take credit • Know & use the political process • Build relationships • Be tenacious but fair • Compromise on methods but not on principles

50. Sell public health … It is often said that public health workers are silent heroes because when we do our work right Nothing happens! Campaign for Public Health Stepping from back stage to in front of the curtain