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 49 th in overall health ranking Significant racial and geographic disparities within Arkansas Fundamental inequity

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

4. 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. http://www.uspreventiveservicestaskforce.org/uspstf/grades.htmhttp://www.uspreventiveservicestaskforce.org/uspstf/grades.htm

12. Recommendation Grid Net Benefit Quality of Evidence SubstantialModerateSmallZero/ Negative GoodABCD FairBBCD Poor = I

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 ” 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). Health Behaviors 40% Environment 5% Health Care 10% Social Factors 15% Genetics 30% Michael D. Warren, MD MPH FAAP, Tennessee Dept. of Health 2013 Amos Christie Lecture

17. 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

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