The Affordable Care Act at Five Years: Where Is Prevention?

The Affordable Care Act at Five Years: Where Is Prevention?
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Five years in, the Affordable Care Act (ACA) has improved the delivery of health care in the United States. But more could be done, especially in preventing disease and promoting wellness, if we are to have a healthier nation in the next generation.

First, let's take a look at some of the success of the ACA. Almost 17 million more Americans have been given insurance coverage and 31 states have expanded their Medicaid programs for the people who are most vulnerable in their states, resulting in a drop in the uninsured non-elderly population to 12 percent. Second, although the United States spent about $3 trillion dollars in total national health expenditures in 2014 and has the highest cost per capita for health care for all industrialized nations, there has been a slowing of the cost curve for U.S. health spending. Major ACA payment reform initiatives for Medicare, including incentives to hospitals to reduce readmissions and infections, have reduced Medicare spending per beneficiary to a rate below inflation.

Millions of dollars are being spent to transform the health delivery system by integrating all parts of health systems, called Accountable Care Organizations, for both Medicare and Medicaid patients. In addition, states are serving as laboratories for health care transformation via the State Innovation Model grants and waiver options awarded to state Medicaid agencies. Many of these efforts include reforming the primary care system by creating medical and/or health homes, integrating behavioral health into primary care, and enhancing care coordination for patients with chronic conditions. All of these efforts are important and will most likely lead to better quality health care and health outcomes for patients. But to truly achieve better health at lower costs, we've got to address all aspects of health, and that includes preventing disease.

One emphasis of the ACA in the past five years has been on assuring that all evidence-based health screenings and other clinical preventive services are implemented. For example, the ACA includes a mandate that all insurers must pay for any clinical preventive service that receives an "A" or "B" recommendation by the United States Preventive Services Task Force. The Centers for Disease Control and Prevention 6|18 initiative is a collaboration with purchasers, payers and providers to accelerate the implementation of 18 evidence-based interventions for a patient within and outside of the clinical setting in six high-burden health conditions through reducing tobacco use, controlling asthma, controlling blood pressure, preventing healthcare associated infections, controlling and preventing diabetes, and preventing unintended pregnancy. That's a start. But it won't get us all the way there.

The United Health Foundation's state rankings for access to health care and chronic disease prevention strategies reveals that there is great variation in states in uptake of immunizations and chronic disease prevention (e.g., whether a patient had a blood pressure screen or a cholesterol check). All the prevention indicators varied by income, race/ethnicity, education and location in the country. States in the Northeast performed much better on these measures than states in the Southeast. Hispanics report receiving less preventive services than non-Hispanic blacks and whites.

The problem? There has been little emphasis on addressing the root causes of poor health by investing in prevention in community settings. Better health for individuals and communities depends on a variety of factors, such as having clean and safe water and food, clean air, as well as safe places to play and exercise. Community-wide campaigns that focus on positive health behaviors are one effective strategy to support and create environments for individuals and families that supports wellness. However, less than 5% of $3 trillion dollars spent on U.S. health care funds public health and related community-based prevention or population health efforts. To date the Prevention and Public Health Trust Fund has provided nearly $5.25 billion (less than .01% of the total health care costs) in additional resources to communities for prevention of disease and promotion of healthy lifestyles.

A new Centers for Medicare and Medicaid Services demonstration effort, called Accountable Communities for Health, is an important step in coaxing health care systems to embrace the larger community in which patients live. Recipients of these new ACH grants are required to connect with public health and community-based organizations to facilitate efforts that will improve the health of the entire community. In addition, several of the State Innovation Model grants (e.g., Oregon, Minnesota, Vermont and Colorado) funded by CMS to state Medicaid agencies have embraced the creation of community health organizations as well. In one case in Oregon, health insurer Trillium is giving $1.33 per member per month to the county health department for community prevention activities in its coordinated care organization. Other insurers should follow this example and dedicate part of their budgets to public health and community providers of population-wide prevention services.

Prevention with a focus on the social determinants of health in a community needs to be an emphasis of the ACA in the next five years. If we fail to do this, the United States will continue to struggle with expanding health care costs and suffer from poorer health outcomes compared to other industrialized nations.

Deborah Klein Walker is a Vice President and Senior Fellow at Abt Associates. She is the current president of the American Orthopsychiatric Association and a former president of the American Public Health Association and the Association of Maternal and Child Health Programs. She served as Assistant and Associate Commissioner for 16 years at the Massachusetts Department of Public Health. The opinions expressed are her own and do not reflect those of Abt Associates.

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