The Affordable Care Act and Its Juncture between Health Care and Health
This is part of a series in which Robert Wood Johnson Foundation (RWJF) leaders, scholars, grantees and alumni offer perspectives on the U.S. Supreme Court rulings on the Affordable Care Act. Sara Rosenbaum, JD, is the Harold and Jane Hirsh Professor at George Washington University, School of Public Health and Health Services, Department of Health Policy. Rosenbaum received an RWJF Investigator Award in Health Policy Research in 2000, and is on the board of the RWJF Health Policy Fellows program.
In affirming the constitutionality of the Affordable Care Act, the United States Supreme Court assured the legal survival, not just of thousands of discrete legislative provisions, but also the big ideas embedded in the Act. One of the biggest is its emphasis on strengthening the juncture between health care and health, an opportunity whose potential is only beginning to be explored. The most publicly visible aspect of this emphasis is the Act’s expansion of coverage for clinical preventive services without cost-sharing across the principal health insurance markets recognized under the Act: Medicare; employer-sponsored health plans, state regulated individual and small group markets (including the new Exchange market) and the Medicaid “benchmark plan” market that will serve newly eligible beneficiaries. (Ironically, the Act leaves out of this expanded clinical preventive coverage design the health plan market serving traditional Medicaid beneficiaries; other than a state option to expand coverage at slightly favorable federal financing rates, the law does not require expanded clinical preventive benefits for the very poorest beneficiaries. Although family planning services are a required benefit for all beneficiaries of childbearing age, services such as screening colonoscopies and adult immunizations remain optional for the traditional coverage group).
But the opportunities to bridge the health/health care divide go well beyond the important, threshold question of coverage design. The biggest opportunities are those that are intended to change the way that two of the principal players in the health care system—physicians and hospitals—envision their role in society and position themselves in communities. In the case of physicians, the Act incentivizes formation of accountable care organizations (ACOs), entities that assume responsibility not simply for health care of a defined group of patients (like any practice network) but for the health of the population they serve. ACOs are expected to move beyond improvements in the quality of clinical services they furnish and to reach into their communities through greater involvement in community health improvement activities. Similarly, the Act expands and strengthens the community benefit obligations of the nation’s nonprofit hospitals seeking federal tax-exempt status, upping their responsibilities related to community health improvement planning, and incentivizing investment in community health improvements and community building.
Even as the Act pushes traditional health care providers toward public health, it expands public health models of care. A prime example of this is the Act’s $11 billion investment in community health center expansion (reduced somewhat in the April 2011 budget agreement, but substantial nonetheless). Another marquee program is the Act’s maternal, infant, and early child home visiting program, which builds on an evidence-based strategy for improving the health of families and their infants and young children.
Finally, the Act’s Prevention Fund makes money available to communities to fashion community health improvement interventions that aim directly at improving healthy behaviors and addressing the social conditions of health. The Centers for Disease Control and Prevention’s Community Transformation Grant (CTG) program is the mechanism by which this investment has been realized
What’s needed to get the most juice out of these investments? The March 2012 Institute of Medicine (IOM) report on bridging primary care and public health outlines a series of steps that will build clinical and community health integration, setting a conceptual framework of a shared belief in population health improvement, community engagement, alignment of leadership, a sustainable infrastructure for making and implementing choices, and better use of data and information.
What’s a good starting point? One is to make sure that CTG awards are made in communities in which ACOs are forming, and establish collaborative activities as a basic expectation for both entities. Conversely, ACOs forming in communities with CTG awards should be expected to reach out.
Another point of entry: Bring CTG and ACO activities together with the burgeoning community health needs assessment activities now being carried out by nonprofit hospitals. Align health center expansion investments with these activities, and establish expectations regarding the interactions among health centers, nonprofit hospital community benefit investments, CTG activities, and home visiting. This means using team-based public administration approaches that involve the federal agencies that oversee these programs, a transformation recognized in the IOM report. It also means building a team outlook within local communities where the investments get made. It also means building on the visionary efforts underway at health professions schools to train a generation of clinical and public health professionals with a foot in both camps.
Nearly 50 years ago, Jack Geiger, one of the nation’s greatest pioneers in the juncture of health care and community health, and a founder of the nation’s first community health centers, was criticized by the Office of Economic Opportunity (OEO) for using health center funds to enable patients to obtain and fill prescriptions for food. When pressed by federal officials regarding the propriety of the OEO expenditure, Jack responded, “The last time I looked, food is the proper treatment for malnutrition.” We need an army of Jack Geigers, who in turn can rely on an integrated health care/public health infrastructure. We also need an ongoing community benefit investment in community health activities that lie beyond the reaches of insurance. And we need agencies with the vision to get us there.
The Affordable Care Act contains invaluable tools for change. Now let’s use them.