1. Public Health 2030: Scenarios for the Boston Public Health Commission 1

2. The Public Health 2030 Scenario Effort Conducted by the Institute for Alternative Futures. Funded by the Robert Wood Johnson Foundation and the Kresge Foundation to: Explore key forces shaping public health Consider the future of public health functions, financing & sustainability Build expectable, challenging & visionary scenarios that facilitate preparation, imagination & aspiration Provide & widely distribute the scenarios as a tool for public health agencies, organizations & schools 2

3. Scenario Zones Visionary/Surprisingly Successful Expectable Challenging

4. Public Health 2030: Scenarios for the Boston Public Health Commission Scenario 1 Smarter Public Health, Missed Opportunities Scenario 2 Under Water Scenario 3 Public Health as Chief Health Strategist Scenario 4 A Renaissance of Civic and Social Responsibility 4

5. SCENARIO 1: SMARTER PUBLIC HEALTH, MISSED OPPORTUNITIES  HIGHLIGHTS 5

6. Boston economy grows in tandem with national economy. – Mild national recessions in 2015 and 2022 – Periodic federal and state cuts and program eliminations Scenario 1: Smarter Public Health, Missed Opportunities 6

7. Climate change: increased sea-level rise, summer heat waves, and increased storm intensity and/or frequency. Scenario 1: Smarter Public Health, Missed Opportunities 7

8. 2018 Hurricane -Called Boston's Hurricane Katrina -Evacuations OK but with disparities in recovery Scenario 1: Smarter Public Health, Missed Opportunities 8

9. In health care, 98% + access to care, and most care is integrated and capitated. More people are effectively assessed and even treated at home, yielding health care savings Hospitals deploy community health workers (CHWs) Scenario 1: Smarter Public Health, Missed Opportunities 9

10. In health care, 98% + access to care, and most care is integrated and capitated. Large health care provider systems routinely improve neighborhood conditions Scenario 1: Smarter Public Health, Missed Opportunities 10

11. In health care, 98% + access to care, and most care is integrated and capitated. Doc Watson, digital health coaches common Scenario 1: Smarter Public Health, Missed Opportunities 11 “Dr. Watson” for Public Health Digital coach (“avatar”)

12. In health care, 98% + access to care, and most care is integrated and capitated. BPHC retains its hold on homeless, addictions, and emergency medical services (EMS) Scenario 1: Smarter Public Health, Missed Opportunities 12

13. Surveillance, emergency prep, analyses improve. – City integrates surveillance systems, Internet of Things Scenario 1: Smarter Public Health, Missed Opportunities 13

14. Surveillance, emergency prep, analyses improve. – BPHC uses games, digital coaches, and simulations to improve health education and emergency preparedness, mitigation, and recovery Scenario 1: Smarter Public Health, Missed Opportunities 14 Personal Health Advocate Avatar V2.1

15. Surveillance, emergency prep, analyses improve. – BPHC more effectively analyzes and targets community conditions shaping health Scenario 1: Smarter Public Health, Missed Opportunities 15

16. But ACOs create their own epidemiology or population health units, turn to universities and private companies for most advanced analytics. Scenario 1: Smarter Public Health, Missed Opportunities 16

17. Key Outcomes Challenging for BPHC to consistently prove its value to HC and get recognized for advisor and convener roles BPHC achieves 3 overarching goals in obesity, low birth- weight babies, and chlamydia Scenario 1: Smarter Public Health, Missed Opportunities 17

18. Key Outcomes Fundamental problems of poverty, social exclusion and homelessness remain BPHC forced to do more with less funding and fewer staff Scenario 1: Smarter Public Health, Missed Opportunities 18

19. SCENARIO 2: UNDER WATER  HIGHLIGHTS 19

20. Boston faces serious municipal finance challenges. City’s economic health & revenue drops – National 2016 recession – 2018 superstorm hits Boston – Reduction in resident students; Decline of Boston education sector 20 Scenario 2: Under Water

21. Over time, cuts leave BPHC to focus on: – infectious disease control and prevention – emergency preparedness – emergency medical services – homeless and addiction services. Scenario 2: Under Water 21

22. Health worsens especially for working poor. Federal health reform was only partially implemented, partially repealed Scenario 2: Under Water 22

23. Health worsens especially for working poor. Addictions funding is integrated into primary care, demand for mental health services increases But payment reductions and provider shortages disproportionately affect the poor Scenario 2: Under Water 23 Shortage of primary care providers

24. Health worsens especially for working poor. Digital health coaches and “virtual doctor” services grow but vary in quality 24 Scenario 2: Under Water

25. Climate change and superstorm drain resources, leave significant physical and economic damages. Hotter summers and related droughts, more intense storms throughout the year, greater potential for infectious diseases and mold Scenario 2: Under Water 25

26. Climate change and superstorm drain resources, leave significant physical and economic damages. Full recovery from superstorm takes years Scenario 2: Under Water 26

27. Climate change and superstorm drain resources, leave significant physical and economic damages. BPHC improves ability to forecast and warn about, for example, likely asthma attacks by neighborhood. – But this often does not lead to earlier response and prevention because of resource constraints Scenario 2: Under Water 27

28. BPHC struggles to be effective and heard. Big Data - Corporations and health care providers hire skilled analysts to do their own big data analytics Big Data - BPHC has to work with growing volume of data with large blind spots for low-income people and people of color 28 Scenario 2: Under Water

29. BPHC struggles to be effective and heard. Public health messaging is tuned out among proliferating competition in a variety of channels, ads, and communications Scenario 2: Under Water 29

30. Key Outcomes Health gaps between the "haves" and "have-nots" worsens Little to no community prevention – stymied by challenges in funding – difficulties in recruiting cross-sectoral partners – lack of political will Scenario 2: Under Water 30

31. SCENARIO 3: PUBLIC HEALTH AS CHIEF HEALTH STRATEGIST  HIGHLIGHTS 31

32. Boston becomes a beacon for the rest of the nation in successfully improving health equity and racial justice. Nationally, strong economic recovery; Prevention Fund restored; “Health in all policies” movement takes hold By 2016, MA passes a living wage law with automatic cost-of-living adjustments Boston’s citywide long term vision for health Scenario 3: Public Health as Chief Health Strategist 32

33. Health care integrates equity lens into clinical practice and outcomes, performance assessments and quality improvement activities. Near-universal coverage in the state, excellent care Systematic screening for health and SDH factors and needs lead to shared investments and programs in systemic solutions for violence prevention and health Scenario 3: Public Health as Chief Health Strategist 33

34. Health care integrates equity lens into clinical practice and outcomes, performance assessments and quality improvement activities. Digital health coaches, social networks, games and simulations guide users toward healthy behaviors Demand for EMS services declines with improved care, services, and prevention Scenario 3: Public Health as Chief Health Strategist 34 Digital health agents, gaming, social networking Prevention

35. Mapping, games, and simulations facilitate community engagement and planning. BPHD develops health dashboards for each community to track progress Virtual simulations and games of Boston’s health allow for exploration and consideration of emergency scenarios and fair access to opportunities for health. Scenario 3: Public Health as Chief Health Strategist 35

36. BPHC uses its convening powers and connections to identify and accelerate promising opportunities and evidence-based practices, initiatives, and policies. BPHC functions as health equity and health promotion coach for Boston government. Enhances and leads effective community health endeavors. Scenario 3: Public Health as Chief Health Strategist 36

37. Key Outcomes Health equity and racial justice improve. Widespread community engagement. Boston’s government becomes a role model. BPHC is widely recognized as the City’s chief health strategist. Scenario 3: Public Health as Chief Health Strategist 37

38. SCENARIO 4: A RENAISSANCE OF CIVIC AND SOCIAL RESPONSIBILITY  HIGHLIGHTS 38

39. Constraints fuel creativity. Nationally, unemployment remains high, another major recession in 2017 is followed by slow and uneven recovery Scenario 4: A Renaissance of Civic and Social Responsibility 39

40. Constraints fuel creativity. Growing excitement around innovative health-improving technologies and vibrant social movement of “civic hacking” (including development of apps to help people manage their health) Scenario 4: A Renaissance of Civic and Social Responsibility 40

41. Constraints fuel creativity. BPHC uses prizes and current funding sources to accelerate innovations and save costs Scenario 4: A Renaissance of Civic and Social Responsibility 41

42. Publicly available simulations and comprehensive data: Enhance impact assessments and evaluations Improve policy design Facilitate funding streams Scenario 4: A Renaissance of Civic and Social Responsibility 42

43. Health care often presses beyond clinical needs to improve population health. Virtually all Bostonians gain access to effective health care Most care is provided through integrated and capitated ACOs Scenario 4: A Renaissance of Civic and Social Responsibility 43

44. Health care often presses beyond clinical needs to improve population health. BPHC joins ACOs and other providers in population and community health endeavors, often as a leader and/or coach Demand for EMS, homeless, and addiction services declines Scenario 4: A Renaissance of Civic and Social Responsibility 44 Community Centered Health Home Triple Aim

45. Key Outcomes Many BPHC functions are taken on by other institutions and consumers; BPHC increasingly shifted to emphasize its role in capacity-building, mapping, and incentivizing the development of public- and private-sector solutions and consumer tools. Scenario 4: A Renaissance of Civic and Social Responsibility 45

46. BPHC's successes inspire other Boston agencies and organizations. BPHC monitors innovations and assures community representation in the innovation process. Scenario 4: A Renaissance of Civic and Social Responsibility 46

47. Key Outcomes Health equity and racial justice improve Innovation platform provides sophisticated decision- making tool that is inclusive of all Bostonians Scenario 4: A Renaissance of Civic and Social Responsibility 47

48. Key Outcomes Many BPHC functions are performed to large extents by other institutions, public- and private-sector solutions, and consumer tools Widespread community engagement, innovation platform provides sophisticated decision-making tool that is inclusive of all Bostonians Scenario 4: A Renaissance of Civic and Social Responsibility 48

49. Scenario 1Scenario 2Scenario 3Scenario 4 MACRO AND OPERATING ENVIRONMENTS Economy Technology Health and health care Citizen science and engagement Climate Change effects and mitigation BOSTON PUBLIC HEALTH COMMISSION Funding IT and informatics Workforce Surveillance and epidemiology Health education and promotion Chronic disease prevention and control Infectious disease prevention and control Violence prevention Etc. See the scenario matrix for a side-by-side comparison of the scenarios across multiple dimensions 49

50. Rate the Likelihood & Preferability of Each Scenario 50 Likelihood (0% to 100%) Preferability (0 to 100) Scenario 1: Smarter Public Health, Missed Opportunities ?? Scenario 2: Under Water ?? Scenario 3: Public Health as Chief Health Strategist ?? Scenario 4: A Renaissance of Civic and Social Responsibility ??

51. Feedback, please! Scenario Process What did you learn from the scenario process? Where there any new or surprising insights? In what ways might it affect: – How you monitor your organization’s environment – The strategies or tactics organization pursues – Your communications, relationships with partners? – What other learning or outcomes would you identify? Scenario Workshop What worked, or was successful about the Scenario Workshop? What would you change? 51