The Affordable Care Act (ACA) and Public Health

Nate Smith, MD, MPH

Director and State Health Officer

Arkansas Department of Health

Health Outcomes in Arkansas

• Arkansans experience worse health outcomes than many other Americans

• 49th in overall health ranking

• Significant racial and geographic disparities within Arkansas

• Fundamental inequity

Infant Mortality Rate

Source: National Center for Health Statistics (NCHS) and Linked Birth/Infant Death Files, Health Statistics Branch, Arkansas Department of Health

Source: Linked Birth/Infant Death Files, Health Statistics Branch, Arkansas Department of Health (provisional data)

Arkansas Red Counties, In Accordance with Act 790 and 798 2009 Life Expectancies at Birth

ACA and Preventive Health Services

• The ACA will markedly expand first-dollar coverage for preventive health services

• USPSTF grade A and B recommendations

• Preventive health services have not been a priority

– higher costs

– poorer outcomes

• ACA provides a reimbursement model for ADH and others to expand access

OverviewThe U.S. Preventive Services Task Force…

•Makes recommendations on clinical preventive services to primary care clinicians

• The USPSTF scope for clinical preventive services include:− screening tests− counseling− preventive medications

• Services are offered in a primary care setting

• Recommendations apply to adults & children with no signs or symptoms

Recommendation GradesLetter grades are assigned to each recommendation statement. These grades are based on the strength of the evidence on the harms and benefits of a specific preventive service. http://www.uspreventiveservicestaskforce.org/uspstf/grades.htm

Recommendation Grid

Net Benefit

Quality of

Evidence

Substantial Moderate Small Zero/

Negative

Good A B C D

Fair B B C D

Poor = I

ACA Coverage of Preventive Health Services

Group health plans and health insurance issuers offering group or individual health insurance coverage shall, at a minimum 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 USPSTF

•Immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) of the CDC

•Evidence-informed preventive care and screenings for infants, children and adolescents provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA)

Guidelines for Women’s Preventive Services

Additional preventive care and screenings not described in paragraph (1) as provided for in comprehensive guidelines supported by HRSA

•Well-woman visits

•Support for breastfeeding equipment

•Contraception

•Domestic violence screening and counseling

Healthcare Access Issues

• Access issues will remain in many rural areas

– Lack of primary care providers in many rural areas

• Innovative strategies to expand access under the ACA

– Utilizing mid-level providers (Advanced Practice Nurses,

Physician Assistants)

– Community health workers

– Telemedicine to provide specialty evaluation and follow up

• ADH has Local Health Units with telehealth equipment in all 75 counties and may help improve access

Determinants of “Health ”

• Health care contributes a small amount to an individual’s overall health and well-being

• Improving Health requires comprehensive focus

Sources: McGinnis JM & Foege WH. Actual causes of death in the United States. JAMA 1993: 270(18):2207-12 (Nov 10)McGinnis JM, Williams-Russo P, & Knickman JR. The case for more active policy attention to health promotion. Health Affairs 2002; 21(2):78-93 (Mar).

HealthBehaviors

40%

Environment5%

HealthCare10%

SocialFactors

15%

Genetics30%

Michael D. Warren, MD MPH FAAP, Tennessee Dept. of Health2013 Amos Christie Lecture

• Population health outcomes are largely determined outside the healthcare setting

– Environmental factors:• environmental exposures• safe food & water• built environment

– Social determinants of health:• poverty• education• social norms

Health ≠ Health Insurance

– Lifestyle choices:• physical activity • food choices• use of tobacco, alcohol and other substances

– Healthcare access:• coverage• available providers• transportation• healthcare seeking behaviors

• The ACA will help to improve individual health but will not be sufficient in itself to change population health.

Beyond the ACA

The Mission of the ADH:

•Helping Arkansans improve their own health

•Protecting the public from epidemics

•Providing preventive health services in your communities