In March 2014, we marked the four-year anniversary of President Obama’s signing of the Patient Protection and Affordable Care Act (PPACA), commonly known as the ACA. It is worth noting that the ACA is designed to realign and encourage collaboration between the public health and health care systems. With the legislation’s focus on insurance reform and health system reform, the ACA includes several provisions that have important implications for public health. The ACA also directly influences public health through the creation of the Prevention and Public Health Fund, the nation’s first mandatory funding for public health, and the first National Prevention Strategy, a sweeping development program that for the first time focuses on individual behavioral choices and the social determinants of health. In this article, we will highlight some of the features of the ACA that directly or indirectly target public health, though it is too soon to say what effect these measures will have on the health of Americans.
Preventive healthcare services under ACA
While the principal goal of the ACA is to improve access to the traditional health care system via expansion of affordable health insurance options, there are specific provisions that expand access to primary and secondary prevention services such as immunizations and regular disease screening. Most health plans are now required to provide preventive health services to plan members without charging a copayment or coinsurance (even if the annual deductible has not been met) as long as those services are delivered by a provider within the plan’s network . Preventive health services included on this guaranteed list are blood pressure and cholesterol screenings, cancer screenings such as colonoscopies and mammograms, and immunization vaccinations for adults and youth (e.g., flu, measles, and mumps). Several behavioral health interventions are also covered at no cost, including alcohol misuse screening and counseling, depression screening, and tobacco cessation counseling and interventions. The ACA also requires free provision of Food and Drug Administration-approved contraceptive methods, although this becomes more complicated for employers with a religious objection to contraception.
New initiatives: The Prevention and Public Health Fund and the National Prevention Strategy
The ACA explicitly called for two initiatives to promote prevention and public health: the Prevention and Public Health Fund and the National Prevention Strategy. The Prevention and Public Health Fund (PPHF) is a funding source established to provide expanded and sustained federal investments in research; surveillance and tracking; and public health infrastructure, workforce, and training. Dedicated funding helps ensure that public health and health care systems are not competing with other government departments for scarce resources. The PPHF contributes to a number of programs, including the National Prevention Strategy, and locally-based grants such as the Community Transformation Grants and the National Public Health Improvement Initiative.
The National Prevention Strategy was developed by the Surgeon General alongside multiple stakeholders, including the heads of seventeen federal agencies and the public, with the overarching goal of increasing the number of Americans who are healthy at every stage of life. The National Prevention Strategy identifies four strategic directions and seven strategic priorities (Figure 1) in order to increase the health of all Americans. The report provides recommended policy, program, and systems approaches for each strategic direction and priority.
One example of a strategic direction is Empowered People, which focuses on developing and implementing ways to support individuals in actively managing their own health . The strategy takes into account many of the barriers to making informed health decisions, including overly complex health information and a lack of health-supportive resources in the community. To address these concerns, the federal government is committed to supporting future research on health literacy and clearer communication with the public under the Plain Writing Act. Empowered People recommends that providers find new ways to share critical health information with patients and to confirm their level of understanding. Community partners are encouraged to support health education for adults and to help create healthy environments that make it easier to eat well and be active.
Efforts to achieve the goals outlined in the National Prevention Strategy are already underway, including the America’s Great Outdoors Initiative, a community-based approach to long-term conservation solutions, and the Neighborhood Revitalization Initiative, an inter-federal agency initiative to help neighborhoods in distress transform themselves into neighborhoods of opportunity.
The Prevention and Public Health Fund has also provided resources to two other notable initiatives: Community Transformation Grants (CTGs) and the National Public Health Improvement Initiative (NPHII). CTGs, awarded via the Centers for Disease Control, give communities the resources to develop and implement initiatives to prevent chronic disease, and to support the dissemination of best practices. As one example, Maryland grantees are using CTG resources to reduce tobacco use, create more tobacco-free spaces, and reduce secondhand smoke exposure in the state . The NPHII was created with the goal of improving care delivery and increasing system capacity. This initiative supports health departments across the country in improving performance and securing a new national accreditation. In 2013, NPHII provided $32.4 million to fund 73 state, tribal, local, and territorial health departments .
Other ACA strategies for improving public health
There are other opportunities created by the ACA to improve public health. The Internal Revenue Service now requires non-profit hospitals to complete a community health needs assessment (CHNA) every three years and report annually the extent to which they are addressing identified needs. Though local public health departments have been conducting CHNAs for many years, this ACA requirement creates an opportunity for hospitals and health departments to collaborate on the assessment and improvement of public health .
The ACA also requires implementation of a National Quality Strategy. This strategy has three aims: better healthcare; affordable care; and “Healthy People, Healthy Communities,” which focuses on improving the health of the US population by supporting proven interventions to address behavioral, social, and environmental determinants of health. The National Quality Strategy also establishes six priorities to promote quality healthcare, and two of those six priorities have clear implications for improving public health: (1) promoting the most effective prevention and treatment practices for the leading causes of mortality, and (2) working with communities to promote widespread use of best practices to enable healthy living .
Although most of the press coverage and educational materials about the ACA have focused on health insurance coverage, there are several facets of the legislation that address public health. Whether these initiatives ultimately improve public health remains to be seen, but there is no doubt that the ACA represents an unprecedented effort by the federal government to incentivize policies and practices that seek to improve the health of the entire US population.
For Further information
You can read more about the National Prevention Strategy at http://www.surgeongeneral.gov/initiatives/prevention/strategy/report.pdf.
1. What are my preventive care benefits? Centers for Medicare & Medicaid Services Baltimore, MD. (Health Care.gov.), Retrieved February 9, 2014.
2. National Prevention Council. National Prevention Strategy. Department of Health and Human Services, Office of the Surgeon General. Washington, DC. 2011.
3. Strategies Snapshot: CTG Health in Action. Centers for Disease Control and Prevention. Atlanta, GA. 2013; Available from: http://www.cdc.gov/nccdphp/ dch/programs/communitytransformation/focus- strategies/index.htm.
4. National Public Health Improvement Initiative. Centers for Disease Control and Prevention. Atlanta, GA. Retrieved February 9, 2014; Available from: http://www.cdc.gov/stltpublichealth/nphii/about. html.
5. Randolph, G.D. and J.H. Morrow, The potential impact of the Affordable Care Act on population health in North Carolina. N C Med J, 2013. 74(4): p. 330‐3.
6. Report to Congress: National Strategy for Quality Improvement in Health Care. Agency for Healthcare Research and Quality. Rockville, MD. , 2011.
Neil Jordan, PhD is a health economist and health services researcher with faculty appointments in Psychiatry & Behavioral Sciences, the Center for Healthcare Studies, and Preventive Medicine. His research focuses on identifying high value services and systems of care for persons with complex chronic illness. Dr. Jordan has taught the Health Economics & Healthcare Financing course in the Feinberg School of Medicine for nearly 10 years, and has a keen interest in understanding the implications of health insurance reform.
Philethea Duckett, MPA, is a first year doctoral candidate studying Health Services and Outcomes Research. She investigates the role health policy and health service design decisions play in mediating disparities in access to care, health care quality, and health outcomes for vulnerable populations.