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Public Health in the Era of Health Reform MEND Conference June 13, 2013 Jonathan E. Fielding, MD, MPH, MBA Director and Health Officer Los Angeles County.

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Presentation on theme: "Public Health in the Era of Health Reform MEND Conference June 13, 2013 Jonathan E. Fielding, MD, MPH, MBA Director and Health Officer Los Angeles County."— Presentation transcript:

1 Public Health in the Era of Health Reform MEND Conference June 13, 2013 Jonathan E. Fielding, MD, MPH, MBA Director and Health Officer Los Angeles County Department of Public Health Distinguished Professor of Health Services and Pediatrics Schools of Public Health and Medicine, UCLA

2 The Affordable Care Act presents unique opportunities for prevention Photo Credit: Doug Mills/The New York Times March No-cost preventive medical services Expanded Access to Coverage Public Health & Prevention Fund National Prevention Strategy

3 DPH’s Immediate Role Enrolling uninsured children and families at DPH and partner agencies (Children’s Health Outreach Initiatives) Ensuring that full complement of needs are met HIV, substance abuse, children with special health care needs 3

4 Potential Challenges Post Health Reform As more individuals access care: ─Professional capacity may not be adequate to meet demand ─“Residually” uninsured may have less access ─Improvements in consumer health literacy and provider cultural competencies will be critical As new players enter the healthcare marketplace: ─Consumer protection will be critical 4

5 Prevention & Public Health Fund The nation’s first mandatory funding stream dedicated to improving public health Originally funded at $15 billion for FY 2010 – 2019 and $2 billion every year thereafter 5

6 In February 2012, legislation reduced the fund by $5 billion over 10 years. The fund is under constant threat of elimination. 6

7 Prevention & Public Health Fund: Community Transformation Grant $9.8 million per year in LA County supports: 1.Tobacco free living 2.Active living and healthy eating 3.High impact clinical preventive services 4.Social and emotional wellness 5.Healthy and safe physical environments

8 Percent of Adults Who Are Current Smokers, by FPL, LA County, Los Angeles County Health Survey, 2011 Los Angeles County, Department of Public Health, Office of Health Assessment and Epidemiology

9 Rethink Your Drink Campaign Sugar sweetened beverages (SSB) are the largest single source of added sugar and calories in the American diet. On average, nearly 39% of adults in LA County drink at least one SSB per day. > 43% of children 17 or younger consume at least one SSB on an average day. –A child’s risk for obesity increases an average of 60% with every additional daily serving of soda.

10 Portion Control Campaign "Choose Less, Weigh Less" With bigger food portions come more calories. Consuming extra calories can lead to obesity, diabetes, heart disease and some cancers. Videos of portion size PSAs can be found at:

11 Underlying Determinants of Health “ Conditions in the social, physical, and economic environment in which people are born, live, work, and age. They consist of policies, programs, and institutions and other aspects of the social structure, including the government and private sectors, as well as community factors. ” Healthy People 2020: An Opportunity to Address Societal Determinants of Health in the U.S., Objectives for 2020, July 11, Top photo credit: New York Times, Beatrice de Gea, Oct 19, 2008.

12 Health Factors Health Outcomes Programs and Policies Mortality (50%) Morbidity (50%) Physical environment (10%) Social & economic factors (40%) Health behaviors (30%) Clinical care (20%) Unsafe sex Alcohol use Diet & exercise Tobacco use Access to care Quality of care Community safety Education Family & social support Employment Income Built environment Environmental quality County Health Rankings model © 2010 UWPHI 12

13 Poverty is a poison without adequate antidotes… but, there are ways to mitigate the effects. 13

14 Partial Antidote: A Healthy Community 1.Meets basic needs of all 2.Provides quality and sustainable environment 3.Maintains adequate levels of economic and social development 4.Promotes health 5.Fosters social relationships that are supportive and respectful Adapted from Health in All Policies Task Force Report to the CA Strategic Growth Council, Dec and presentations by CDPH, Linda Rudolph, MD, MPH.

15 Adverse Health Impacts From Poor Community Design  traffic safety  air pollution  water quality & quantity  obesity & chronic disease  physical activity  crime & violence  social capital  elder health & mobility  mental health  health disparities

16 Bottom 10 * City/Community Name Obesity Prevalence (%) Rank of Economic Hardship ( ) West Athens South Gate Florence-Graham West Whittier-Los Nietos West Carson Vincent East Los Angeles Hawaiian Gardens South El Monte Walnut Park Average 10 highest32.7% Ave Median Household Income$37,747 Top 10 * City/Community Name Obesity Prevalence (%) Rank of Economic Hardship ( ) Manhattan Beach3.42 Calabasas5.08 Hermosa Beach5.11 Agoura Hills5.310 Beverly Hills5.419 Malibu5.94 Palos Verdes Estates7.35 San Marino7.815 Rolling Hills Estate8.49 La Canada Flintridge8.518 Average 10 lowest6.2% Ave Median Household Income$99,555 *Table excludes cities/communities where number of students with BMI data < 500. Source: CA Physical Fitness Testing Program, CA Department of Education. Includes 5th, 7th, and 9th graders enrolled in LAC public schools; 2000 Census Cities/Communities with Lowest and Highest Childhood Obesity Prevalence,

17 DPH Efforts toward Healthy Communities Key strategies:  Provide grants to cities & non-profits to create safe routes to school plans, bicycle/pedestrian master plans, complete streets etc.  Influence regional transportation policies to support PH goals  Facilitate development of “joint use agreements” between schools and cities  Expand access to healthy foods via community market conversions, promotion of farmers markets  Support recreational programming and health education at regional parks in high-crime communities (“Parks After Dark”) :

18 Age (years) Relative magnitude of influence Adapted from Nordio S Needs in Child and Maternal Care. Rational utilization and Social Medical resources. Riviests Italiana de Pediatria 4:3-20. As cited in Halfton, N., M Hochstein The Health Development Organization: An Organizational Approach to Achieving Child Health Development, The Milbank Quarterly 78(3): Health Influences Over the Lifetime 18

19 Partial Antidote: Healthy Early Childhood and Before 19 Right photo credit: Cade Martin, CDC

20 20 Preconception –Maintain healthy weight –Folic acid supplementation Prenatal –Early care –Healthy weight gain –Disease screening (e.g. Diabetes) Maternal obesity in early pregnancy more than doubles risk of obesity in child 2-4 years old ¹ 1. Whitaker, R.C. Predicting Preschooler Obesity at Birth: The Role of Maternal Obesity in Early Pregnancy. Pediatrics :e29-e36. Prevention Before Day One

21 21 Best health outcomes are associated with: exclusive breastfeeding sustained breastfeeding Breastfeeding = Optimal Infant Nutrition

22 Acute Otitis Media Atopic Dermatitis GI (non- specific) Asthma Type 2 Diabetes Childhood Leukemia SIDS Obesity Ip S, Breastfeeding and maternal and infant health outcomes in developed countries. Rockville, MD: U.S. Dept. of Health and Human Services, Public Health Service, Agency for Healthcare Research and Quality; AcuteChronic Breastfeeding – Prevention for Babies Risk Differences for Various Diseases

23 Early Childhood Education Head Start enrollment has been linked with a reduction in childhood obesity and decreased smoking prevalence later in life 1 Preschool leads to long-term gains in cognitive ability and socialization 2-6 First 5 LA working as an equalizer across LAC 23 1) Ludwig J, Phillips DA. The benefits and costs of Head Start. Cambridge MA: National Bureau of Economic Research, 2007; 2) Barnett WS. Long-term effects of early childhood programs on cognitive and school outcomes. The future of children. 1995: ) Bowman BT, et al. Eager to learn: Educating our preschoolers: National Academy Press; 2001.; 4) Yoshikawa H. Long-term effects of early childhood programs on social outcomes and delinquency. The future of children. 1995:51-75; 5) Gomby DS, et al. Long-term outcomes of early childhood programs: Analysis and recommendations. The future of children. 1995:6-24; 6) Henry GT, et al. Georgia pre-k longitudinal study: Final report Atlanta, GA: Georgia State University, Andrew Young School of Policy Studies

24 Partial Antidote: Improving Educational Outcomes 24

25 Years of School Completed Robert Wood Johnson Foundation. Overcoming Obstacles to Health: Report from the Robert Wood Johnson Foundation to the Commission to Build a Healthier America. February Education Matters: More Formal Education = Longer Life Expectancy 25

26 Years of School Completed by Mother, All Ages Robert Wood Johnson Foundation. Overcoming Obstacles to Health: Report from the Robert Wood Johnson Foundation to the Commission to Build a Healthier America. February And It Matters to the Next Generation: Mother’s Education Related to Infant Mortality 26

27 Percent of Adults with Less than a High School Diploma, by Race/Ethnicity, LA County 27 Note: African American, Asian, Pacific Islander, and American Indian Alaska Native categories include persons reporting both Hispanic and non-Hispanic Origin, therefore categories are not mutually exclusive U.S. Census Bureau, Year American Community Survey, Table B15002 &C15002

28 Additional Partial Antidotes: Vocational training Job placement services Literacy programs English as Second Language (ESL) Courses Child care supports Elderly/disabled care supports Affordable housing supports Unemployment coverage Access to legal services 28 Photo credit: Ruby Washington, New York Times

29 Challenge with Partial Antidotes for Poverty Scale Sustainability Interconnectedness 29

30 Sustainable solutions require many sectors together to strategically create healthy communities and improve social environments 30 Reversing the Poison

31 Policies as Levers of Change 31 Agriculture: Direct agricultural subsidies toward more nutritious food (corn/corn syrup  fresh fruits and vegetables) Transportation: Increase development and utilization of mass transit (less driving  more walking  better air & weight loss) Advocate for complete streets initiatives with bike lanes, marked crosswalks Environment: Support environmental policies to improve air quality (e.g. cleaner energy sources, land use regulations) Tax: Use tax policy to reduce percentage in poverty - Increase proportion of eligible residents claiming EITC - Use tax as an incentive/disincentive (e.g. tobacco tax)

32 More Work to Be Done Health reform has kick-started important changes and more work is needed to improve our local physical and social environment s Health and well-being are dependent on an interplay of factors Public Health has to engage partners about short- and long-term health implications of decisions and policies (i.e. Health in All Policies) 32


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