Public Health and Health Reform: A Preliminary Scorecard
Peter Jacobson | Leave a Comment
In this post, I offer my sense of how the House and Senate health reform bills compare on their public health provisions. Before submitting my scorecard so far, there are some programs/details not covered in my earlier posts (16 and 26 December) that should be mentioned.
Federally Qualified Health Centers (FQHCs). Both bills would expand FQHCs (also known as community health centers). The House bill is especially generous, allocating $12 billion to their expansion. Most observers agree that FQHCs and free clinics will still be a vital part of the safety net even if the proposed health reform legislation is enacted.
Equally important, Section 3400 of the House bill would permit the Secretary to award grants to establish a community-based collaborative care network. Two aspects of the legislation are particularly relevant to public health. First, the program is designed to manage chronic conditions. Second, it would “increase preventive services, including screening and counseling, to those who would otherwise not receive such screening.” As an adjunct to the funding for FQHCs, this section focuses on coordinating care within a community to ensure primary care coverage for uninsured populations.
School-Based Health Clinics. Both versions require the HHS Secretary to establish grants for school-based health clinics. While the details differ, both would give funding preference to medically underserved areas.
Other Health Centers. The House bill goes beyond the Senate version to add programs for nurse managed health centers and federally qualified behavioral health centers. These are important public health programs, especially for low income populations. Studies have shown that nurse managed clinics are effective primary care resources, and clinics face a growing population presenting with depression. The House’s screening and intervention programs (Section 2538) could be especially helpful in early diagnosis and treatment for mental health.
Dental Health. The Senate bill would establish (subject to available appropriations) a 5 year public education campaign to improve oral health care prevention and education. This program does not even come close to what is needed, but at least it identifies an important public health concern that could form the basis for subsequent program development.
Obesity. The House bill requires the Secretary to establish a “community-based overweight and obesity prevention program.” Funding preferences would go to communities with high levels of obesity and related chronic diseases. The bill allocates $10 million for FY 2011.
Both bills include important workforce development provisions. For instance, Section 2231 of the House bill would establish the Public Health Workforce Corps within the Public Health Service. The bill would also establish workforce scholarship and loan repayment programs. Section 2232 goes further and would establish a public health workforce training and enhancement program through federal grants and contracts. It is designed to provide additional training to midcareer public health professionals and to provide traineeships and fellowships for public health students. (With the exception of the student traineeships and fellowships, which I didn’t find, the Senate bill contains similar workforce provisions.) Public health is sorely lacking in the ability to offer students the kinds of fellowship opportunities that have been available to health management students for many years. Traineeships and fellowships are essential for attracting the brightest students to the field.
The Scorecard So Far*
The House version is superior. It pays far more attention to infrastructure needs than the Senate.
Wellness and Prevention
There is much to like in both bills. Though it’s a close call, on balance, I prefer the Senate’s version for two reasons. One is the Healthy Communities section. The other is the Senate’s emphasis on research for evidence-based prevention programs. (Rather self-serving of me.) But the House’s specific obesity program is important.
Either version would benefit the next generation of the public health workforce. The Senate has a nice provision to establish a public health sciences track, but the House contains traineeships and fellowships for public health students.
The House version is superior because it includes a Public Health Investment Fund that is more prescriptive than the Senate’s vague funding provisions.
Again, the versions are reasonably close, but the House’s addition of nurse-based clinics and the community-based collaborative care network give it the edge.
- Prevention—poor, especially in 4th quarter defense against weak teams
- Wellness—poor, with injuries to key personnel causing prolonged work absences
- Workforce—inadequate, particularly on special teams and pass defense
From what I’m reading, it looks like the Senate’s version will dominate the conference committee deliberations. Even though neither bill offers a comprehensive public health program, adopting either version represents significant benefits and gains to public health. If my interpretation of the two bills is reasonable, adding the House version’s infrastructure and funding arrangements would result in a bill that would deserve full support from the public health community.
*Disclaimer: I lack Tim Jost’s penchant for the details of the legislation, so I may have missed programs or overlooked details of programs that might result in a different scorecard.