What’s the Role of Local Health Departments in Implementing the Affordable Care Act?
The Affordable Care Act (ACA), which kicks into high gear in January, was front and center at the recent annual meeting of the National Association of County and City Health Officials (NACCHO) in Dallas. U.S. Centers for Disease Control and Prevention Director Tom Frieden, MD, MPH, addressed the benefits to population health of many of the new law’s provisions and Kathleen Sebelius, Secretary of the Department of Health and Human Resources, which has overall responsibility for the law, spoke about the ACA via video.
For the most part, the role of local health departments under the ACA is still emerging and will become better known as more provisions are implemented and clarified.
To better understand what we know about that role and what will become better known down the road, NewPublicHealth spoke with Michelle Chuk Zamperetti, MPH, Senior Advisor and Chief of Public Health Infrastructure and Systems for NACCHO.
NewPublicHealth: Are there specific provisions under the ACA that apply to local health departments?
Michelle Zamperetti: There are no provisions specifically designated for local health departments but there are many provisions that impact local and state health departments. For example, many will be involved in the outreach and enrollment efforts for the new marketplaces and some will be designated as navigators to help people enroll for health insurance coverage in both the state-run marketplaces and the federally funded exchanges. For example, I recently learned that authorities managing a state-based health insurance exchange were not pleased with some of the navigator program applicants, so they reached out to a local public health director and asked that health department to be the navigator program leader in their region. And even in communities where health departments don’t give direct enrollment assistance—such as filling out paperwork online—we are confident that people with established relationships with their health department may use it as an entry point for finding out about health insurance, and health departments will need to know how to help them enter the system.
In addition to the insurance expansion provisions of the law, there are also important provisions to strengthen the coverage provided through insurance, particularly in the area of clinical preventive services. For health departments that provide direct services, there are opportunities to become in-network providers under the ACA.
NPH: Do you think many health departments will work together with non-profit hospitals, which now have a mandate from the Internal Revenue Service (IRS) to provide some form of community benefit in order to maintain their tax-exempt, not-for-profit status under the ACA?
Zamperetti: Under the IRS mandate, not-for-profit hospitals are required to do a community health needs assessment every three years to maintain their 501c(3) status. They are required to not only make that assessment public, but also provide information to the community about how they’re addressing the highest priority issues. Most health departments are actively involved in community needs assessments. It is mutually-beneficial for health departments and hospitals to work together on these efforts. Some examples of hospital/health department collaborations can be found on NACCHO’s website in a section called “Stories from the Field.”
The ACA provision does not specifically require local health departments to work with hospitals, although it encourages collaboration and there is important value in doing so. Such collaboration can lead to better outcomes for both the health department and the non-profit hospital.
NPH: Are there ACA provisions that may bring in revenue for health departments?
Zamperetti: I have spoken with many health officials who said they’re working with health systems in their community, but not necessarily getting money. But they are glad to be working collaboratively.
Though I would not consider this revenue, the Prevention and Public Health Fund established under the ACA has provided for a lot of resources that have gone to local health departments, whether it’s through the National Public Health Improvement Initiative, Community Transformation Grants, diabetes grants or other infrastructure improvement grants. The ACA has offered many additional resource opportunities to state and local health departments and this is a significant benefit, but there are still significant changes on the horizon and the impacts of those changes are yet to be seen. Health departments are really only at the beginning of the health reform journey.
A potential source of revenue for local health departments through the ACA is the ability to bill for prevention services, such as immunizations. This has the potential to be a valuable asset for local health departments, but many health departments are not currently set up to bill for these services. NACCHO is providing some support and assistance to health departments who want to increase their capacity to bill Medicaid, Medicare and private insurance companies, but getting into that business is proving to be a challenging process for some.
NPH: Is it important for local public health to know that the Affordable Care Act is a work in progress?
Zamperetti: It is incredibly important for local health departments to stay on top of what’s going on both in their state and with the federal government. It is equally important for everybody in the health system to recognize the role local health departments play in the community. Local health departments are on the front lines of public health. People may not always see the work they do, but we are all safer and healthier because of it. So, understanding how health departments are preparing for, engaging in and feeling the effects of the ACA over the next six to 12 months is really going to be able to help illustrate where we go from here.
What we have is an evolving natural experiment. We will start to see different impacts on local health departments in Medicaid expansion states as compared to non-expansion states soon. [Editor’s Note: Some states are choosing to expand Medicaid to eligible adults in their community; others are not.] In January 2015—a year after implementation begins—NACCHO will be able to share examples about the different ways local health departments have navigated the changes in public health as a result of ACA implementation. We will also be able to reflect on the numbers of people covered, the types of services that local health departments are providing and the ways that health departments are serving as resources to healthcare partners in the community. NACCHO, as a public health leader and voice of local health departments, will be more capable of providing technical assistance and training for local health departments once we start seeing results.
This next year is going to be quite an adventure. Obviously, 25 million people will not be enrolled into the program between October 2013 and March of 2014, but some communities will be much more effective than others. We need to tell their stories—the successes and the challenges. We need to understand the unintended consequences. We need to help figure out what the next chapter of governmental public health looks like.
Health departments will start to engage and ready their own environments in those states that are not currently expanding Medicaid to eligible adults, an option for states under the ACA that is done at the state’s discretion. I think it is likely that over time more states will expand.
Another thing we should pay attention to is the large number of people that will still be ineligible for coverage under the ACA. Those people will still need care. Where will they go? Will state and federal dollars still be available to support those people? What will the impact be if they do not have a place to go? Will local health department and other traditional “safety net providers” have resources to support them in the ways that they used to? Providing care to this uninsured group will still be of critical concern to local health departments.
NPH: What are other areas where local health departments have to get up to speed on the ACA?
Zamperetti: One of the other areas where local health departments really have to start moving forward, if they haven’t already done so, is in the area of health information technology. They have to get their informatics capacity up to speed in order to be able to transmit data and to become eligible for payment.
Local health departments use health information technology to build and sustain collaborations with local, state and federal government partners, as well as other strategic partners in the local public health enterprise, such as hospitals and healthcare providers. Federal government programs provide incentives to healthcare providers such as hospitals and physicians’ offices to adopt and use electronic health records and exchange data, and send data to public health departments for analysis. In order to receive incentive payments, healthcare providers must demonstrate meaningful use of certified electronic health records technology. Unfortunately, federal requirements do not address local health departments’ ability to receive and analyze the data, and they do not receive the same incentives.
- Learning the specifics of the Affordable Care Act, with its myriad of regulations and implementation dates, will take some studying for both consumers and health officials. The Kaiser Family Foundation has released a new video, "The YouToons Get Ready for Obamacare," that can help. "This cartoon is meant to demystify a complex law and explain what it means for you, whether you support or oppose Obamacare,” says Drew Altman, president of the Foundation.
Other ACA resources from the Kaiser Family Foundation to help people understand changes under the ACA include a health insurance subsidy calculator for people whose incomes make them eligible for a subsidy, an interactive ACA implementation timeline, frequently asked questions and a ten-question quiz on the law.
- The National Association of County and City Health Officials has content and resources about the ACA on its website.