Affordable Care Act: Implications for Public Health Marty Fenstersheib, MD, MPH Health Officer Santa Clara County

Overview For the first time, an ongoing investment in prevention and public health Moving from a “sick care” system to a wellness- based system. The health of the individual is inseparable from the health of the community. Public Health and Medical Care need to be equally strong components. Focus on prevention to improve the public’s health and help control costs – $2.3 trillion on medical care (17% of GDP) – 95 cents of each care dollar is for treating illness – US health system ranks 37 th in world

© 2008 Santa Clara County Public Health Department The Public Health Department is owned and operated by the County of Santa Clara. Leading causes of mortality in SCC Source: California Department of Public Health, Death Records, 2007 Top 2 causes, 50% of all deaths Total number of deaths = 8772

Leading causes of preventable deaths in the United States in the year 2000 CauseNumber of deaths resulting Tobacco Smoking435,000 deaths or 18.1% of the total deaths OverweightOverweight and ObesityObesity365,000 deaths or 15.2% of the total deaths. Alcohol consumption85,000 deaths or 3.5% of the total deaths. Infectious diseases75,000 deaths or 3.1% of the total deaths. Toxicants55,000 deaths or 2.3% of the total deaths. Traffic collisions43,000 deaths or 1.8% of the total deaths. Incidents involving firearms29,000 deaths or 1.2% of the total deaths. Sexually transmitted diseases20,000 deaths or 0.8% of the total deaths. Drug abuse17,000 deaths or 0.7% of the total deaths. 12]

Prevention can make a difference Tooth Decay is most common chronic disease in children (fluoridation, sugar education) Half the adults and 1 in 4 children are overweight or obese (exercise, good nutrition) 10% of adults and youth smoke regularly (stronger tobacco policies, taxes) More than 1 in 4 adults have high blood pressure or high cholesterol (diet and activity)

1999 Obesity Trends* Among U.S. Adults BRFSS, 1990, 1999, 2009 (*BMI 30, or about 30 lbs. overweight for 5’4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Prevention as a National Priority Creates a National Prevention, Health Promotion and Public Health Council charged with developing a national Prevention Strategy Creates a Prevention and Public Health Fund designed to expand and sustain the necessary infrastructure to prevent disease or detect it early ($15 Billion over 10 years; starts with $500 million this year to $2 Billion in 2015)

Prevention and Public Health Fund Funding in 4 Critical Areas ($250m FY 2010) – Community and Clinical Prevention in areas such as tobacco control and obesity (CPPW) – Public Health Infrastructure (IT, workforce training as well as epidemiology and laboratory capacity grants – Research including data gathering and surveillance to evaluate preventive services impact – Training of existing and next generation public health professionals

What’s in it for the Individual Clinical Preventive Services (Health Plans) – Plan years beginning 9/23/10, all new group or individual policies must cover without a share of cost Preventive services graded “A” or “B” including breast cancer screening, cervical cancer, HIV, colorectal cancer screening, alcohol abuse counseling, tobacco cessation, obesity screening Immunizations recommended by CDC Preventive care and screening for infants, children

What’s in it for the Individual Medicare Coverage of Clinical Preventive Services (starting January 2011) – Waives coinsurance requirements for most preventive services; Medicare pays 100% – No coinsurance required for initial physical examination

What’s in it for the Individual Medicaid Coverage of Clinical Preventive Services Expands preventive services as well as adult immunizations and their administration States that cover these additional services and vaccines and prohibit cost sharing would receive an increased federal assistance percentage (1%). Begins in 2013

Community Prevention Community Transformation Grants – Competitive grants to state and local governmental agencies and community- based organizations to reduce chronic disease rates, address health disparities and develop a stronger evidence base of effective prevention programs

What’s in it for Business Promotion of wellness in the workplace – Grants for small business to provide comprehensive workplace wellness programs – CDC must survey worksite health policies and programs nationally

Additional Prevention Provisions Immunizations: – States can purchase vaccines at better prices – Demonstration projects (for States) to improve immunization rates Nutrition Labeling at Chain Restaurants Public Health Workforce Increasing the supply of health care workers Enhancing existing work force education and training (loan repayment program) Creates a National Health Care Work Force Commission

Additional Prevention Provisions Bolsters primary care workforce that can promote prevention. $1.5 Billion for the National Health Service Corps between 2011 and 2015 to place health care professionals in underserved areas Over 40 categorical programs in research, chronic disease prevention, aging, school health, maternal and child health, disease surveillance, community health centers, school-based health centers, health disparities/data collection

Possible Causes for Concern Is there still too much emphasis on the medical care side of the equation and potential redirection of public health funds to support medical care expansion Will prevention programs be sustainable Will secondary prevention replace primary prevention

Challenges The Challenge to Public Health is to expand partnerships with medical care community in order to promote full spectrum of Prevention Strengthen collaboration with schools, businesses, municipalities, transportation and others