With the sturm und drang over the public option, extension of Medicare to those between 55 and 64, abortion coverage, cost controls, etc., in the Patient Protection and Affordable Care Act, H.B. 3590, there has been scant attention to the Act’s public health provisions. In this post, I’ll take a preliminary look what the Act includes and omits on public health. This post is intended to be a broad overview. In a subsequent post, I plan to examine the provisions in greater detail. (I’m only covering the Senate bill because it’s the one that is most likely to be enacted into law.)
Perhaps surprisingly, there’s a lot of good news for public health practitioners and advocates. If it’s not everything public health proponents would desire—far from it—it is certainly more than I anticipated would be included.
That said, it’s important not to overstate the potential of the legislation to improve population health. For one thing, it’s hardly a coherent program. Instead, the legislation is structured in five subtitles under Title IV—Prevention of Chronic Disease and Improving Public Health—that do not present consistent themes. For another, the focus is on prevention, with limited attention to infrastructure needs. Nonetheless, as described below, there is considerable potential for the Act to restore public health’s importance to the health care debate.
What comes through the provisions is an expanded federal role in public health without a clearly defined rationale for what that role should be or how this legislation might ultimately define it vis-à-vis the traditional state and local control over public health delivery. For instance, several federal agencies are involved, but the provisions make no attempt to outline a comprehensive federal program. Even so, the legislation would clearly put in place some desirable elements that could be expanded in subsequent regulations and legislation.
Here are some of the bill’s highlights. Instead of listing the specific sections, the following organizes the bill according to my synthesis of a few specific topic areas covered.
Public Health Systems
Research. For public health practitioners and researchers, the good news is that many of the provisions anticipate pilot programs that are evidence-based and require robust evaluation. In every subtitle, the emphasis on evidence-based public health practices and developing innovative approaches is paramount and unmistakable. Likewise, almost every demonstration program requires a robust evaluation. In a field that has not always evaluated its programs, this is a significant set of provisions. It also provides a greater opportunity to establish practice-academic partnerships.
The clearest indication of support for public health systems research is Section 4301, which mandates the HHS Secretary to fund research on evidence-based practices “on high priority areas…in the National Prevention Strategy or Healthy People 2020…,” and translate the research into effective programs. An important corollary is to fund research on the organization, financing, and delivery of public health services. Unfortunately, the legislation does not designate the funding range to be allocated.
Despite the Act’s limitations, the potential for a tremendous expansion of evidence-based public health research and evaluation would be a welcome complement to several Robert Wood Johnson Foundation programs supporting public health systems and public health law research, along with practitioner-based research networks.
Healthy Communities. If this legislation is enacted and funded sufficiently, we may look back on Subtitle C, Creating Healthier Communities, as a stimulus to the revitalization of state and local public health. This section is broadly written to create a grant program for state, local, and tribal health departments to implement, evaluate, and disseminate evidence-based community prevention initiatives to reduce chronic disease rates, address health disparities, and develop stronger prevention programs.
If I’m reading the section correctly, and if funded adequately, it has the potential for transformative change, both structurally (because funds may be allocated to infrastructure) and culturally (because it properly places community health at the center of the public health enterprise. Simply stated, the overall goal is to create healthier lifestyles. Grant recipients will have considerable flexibility to develop innovative programs to achieve the legislation’s broad policy and programmatic objectives.
As an example, funded activities include “creating healthier school environments…, promotion of healthy lifestyle…, and prevent[ing] chronic diseases.” It seems to me that Congress has intentionally established an opportunity to fund a broad range of creative and innovative public health programs. Assuming that HHS funds the program and doesn’t impose restrictive conditions, state and local health departments can attack the built environment, nutritional deficiencies, and much more. But a limitation is that no specific funding amount is authorized.
Public Health Systems. One of the few provisions dedicated specifically to public health systems is Section 4304, which would establish an Epidemiology Laboratory Capacity Grant Program for state, local, and tribal health departments. The goal is to improve surveillance capacity. The section authorizes $190,000,000 for each FY from 2010 through 2013.
Health Disparities. Section 4302 provides for extensive data collection and analysis to identify and monitor trends in health disparities at both the state and federal levels. But the legislation seems limited to data collection and analysis as opposed to developing strategies to reduce disparities.
Public Health Workforce. For state and local public health departments, not to mention Schools of Public Health (including mine), Section 5204 provides a potentially significant boost to the next generation of public health workers. Under this provision, the HHS Secretary is authorized to establish a loan repayment program “to ensure an adequate supply of public health professionals.” In view of an aging public health workforce, the $195,000,000 in loan repayments authorized for FY 2010 will be essential in encouraging the next generation of public health students to pursue a career in state and local public health. Section 5205 provides a corollary loan forgiveness program for allied health professionals. And Section 5207 authorizes $60,000,000 in FY 2010 to train mid-career public health practitioners.
Another piece of good news is the Act’s disease prevention provisions. Throughout the prevention provisions, there is a general thrust that prevention matters and that it works. Success, of course, depends on the subsequent willingness to fund state and local programs. But the federal commitment to prevention is noteworthy. In a transmittal letter to Senator Reid (18 November 2009), CBO estimates that Subtitle A will add $12.9 billion to direct spending between 2010 and 2019. Unfortunately, there is no corollary estimate for potential health care savings during that period based on successful prevention strategies.
Section 4001 establishes the National Prevention, Health Promotion and Public Health Council within HHS to “provide coordination and leadership at the Federal level, and among all Federal departments and agencies, with respect to prevention, wellness and health promotion practices….” A related Advisory Group would develop a “national prevention, health promotion and public health strategy….” Indeed, most of Section 4001 refers specifically to revamping the federal government’s role in prevention and health promotion.
As noted above, the Act contains very little that could be construed as supporting the state and local public health infrastructure, even while encouraging important public health prevention programs. A good set of examples falls under Subtitle B. Section 4101 provides grants (in unspecified amounts) to establish school-based clinics. (Along with Section 5208, which establishes grants for nurse managed clinics, school-based clinics could also be considered in a separate access to public health services category. I’ll address that in a subsequent post.)
Sections 4103 and 4104 deal with prevention and wellness under Medicare, while Section 4106 is designed to improve access to prevention services for Medicaid recipients. These provisions offer an opportunity for public health departments to contract with schools and private sector health care providers to provide the appropriate prevention services. Potentially, these provisions could reinvigorate non-governmental health care organizations to become more involved in public health. In Subtitle C, Sections 4202 and 4203 focus on prevention for Medicare recipients.
Specific Public Health Programs. At the end of Subtitle B, the bill adds two specific public health programs. Section 4107 provides for tobacco cessation services for pregnant women (including cost-sharing waivers. Section 4108 provides grants to states to develop Medicaid initiatives to prevent chronic disease. (As I said, this is not a comprehensive or coherent set of public health initiatives!) What’s most encouraging about Section 4108 is that states will be expected to test innovative, evidence-based approaches to encourage behavioral change (i.e., weight reduction, lowering blood pressure). Under this section, states will be given considerable flexibility to develop the initiatives and will be required to contract with an external partner to evaluate the strategies.
A third specific public health program in contained in Section 4205. This section would apply uniform, national nutritional labeling standards to all standard menu items in a restaurant that is part of a chain with 20 or more locations offering a standard menu. Among other requirements (and subject to certain exceptions), the covered restaurants would be required to disclose the nutrient content and suggested daily caloric intake in close proximity to the menu item.
Health Promotion Media Campaigns
The legislation supports extensive health promotion media campaigns. For instance, Section 4102 would establish a 5 year national oral health care prevention education campaign.
Whether the public health portion of the legislation will be successful depends in part on its funding mechanism. Although the legislation would create many new task forces and advisory committees, funding is not specified (i.e., “out of any funds in ‘x’ department not otherwise appropriated”—every department with unappropriated funds to spare, please raise your hands!). In other instances, funding will be diverted from existing sources. At the same time, the legislation also authorizes new funding for implementing the prevention programs. For instance, Section 4002 allocates $1.5 billion in FY 2014, and $2 billion for each subsequent FY to prevention programs funded under the Public Health Service Act. In contrast, Section 4003 establishes a Preventive Services Task Force, but authorizes “such funds as may be necessary for each fiscal year….”
Another important indicator of success will be the willingness to fund state and local programs, not just federal government councils and advisory groups. The concern is that instead of investing in state and local programs, the legislation will result in a subtle shift away from federal and local control toward a greater federal presence that contains lots of promises with limited implementation. A good example of this is Section 4004’s array of health education outreach and media campaigns. The legislation authorizes up to $500,000,000 for the activities, yet requires CDC to fund these activities instead of similar grants to state and local programs. In contrast, the Healthy Communities provisions are designed to reinforce state and local health departments. Over time, we might see more state-federal cooperation on public health. Depending on one’s perspective, this may not be particularly beneficial to state and local public health officials.
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