1. The Affordable Care Act (ACA) and Public Health
Nate Smith, MD, MPH
Director and State Health Officer
Arkansas Department of Health

2. 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

3. Infant Mortality Rate HP2010 Goal: IMR=4.5
Source: National Center for Health Statistics (NCHS) and Linked Birth/Infant Death Files, Health Statistics Branch, Arkansas Department of Health

4. Figure 7
Source: Linked Birth/Infant Death Files, Health Statistics Branch, Arkansas Department of Health (provisional data)

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

8. 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

10. Overview The 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

11. Recommendation Grades
Letter 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.

12. Recommendation Grid Net Benefit Quality of Evidence Substantial
Moderate
Small
Zero/
Negative
Good A B C D
Fair
Poor = I
TO GET A GRADE, THERE MUST BE GOOD OR FAIR EVIDENCE. Otherwise rating is I. “A” REQUIRES SUBSTANTIAL BENEFIT AND GOOD EVIDENCE “B” REQUIRES AT LEAST MODERATE BENEFIT.
Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.
Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.
Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.

13. 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)

14. 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

15. 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

16. Determinants of “Health ”
Michael D. Warren, MD MPH FAAP, Tennessee Dept. of Health
2013 Amos Christie Lecture
Determinants of “Health ”
Environment 5%
Health care contributes a small amount to an individual’s overall health and well-being
Improving Health requires comprehensive focus
Health Care
10%
Health
Behaviors
40%
Social
Factors
15%
Genetics
30%
Sources: McGinnis JM & Foege WH. Actual causes of death in the United States. JAMA 1993: 270(18): (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).

17. Health ≠ Health Insurance
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

18. 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.

19. 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