Health Departments Begin Implementing the Affordable Care Act: NACCHO Annual

Jul 11, 2013, 1:52 PM

file The view of Dallas, Texas, from the 2013 NACCHO Annual Conference.

With just 83 days to go until health insurance marketplaces open up to allow otherwise uninsured Americans to sign up for health coverage under the Affordable Care Act (ACA), NACCHO Annual has a good number of plenary and other sessions focused on the role of public health in implementing the law. 

>>Read more NewPublicHealth coverage of NACCHO Annual.

In his address to the 1,000 plus attendees at this year’s NACCHO conference, Centers for Disease Control and Prevention Director Tom Frieden, MD, MPH, talked about what local health departments can do to support ACA. “This is an all hands on deck situation,” said Frieden. “We want to do a lot with improving quality of care, but first we’ve got to get people signed up.”

Frieden ticked off actions that local health departments can take to help support enrollment, including:

  • Provide resources to the community on getting insured & the benefits of being insured, including free preventive care.
  • Educate every resident served by the department, such as immunization, tuberculosis and STD clinic patients, on how they can enroll.
  • Educate every organization that the health departments connects with, such as schools, courts and businesses, on how stakeholders can enroll.

As previously uninsured people become covered, the role of public health continues to be critical, said Frieden. “We are the data people. We can identify community health and clinical trends and help providers identify what’s most important to focus on [to improve population health].” Frieden gave a critical example: “The one most important indicator that could save the most lives is to control blood pressure. It kills more people than any other underlying cause. We’re only at 50 percent controlled, even among [people who are currently] insured,” said Frieden.

At today’s opening sessions, several local and state health leaders shared how they are implementing the ACA in their communities. Implementation varies because not all states are taking up the option of expanding Medicaid to adults and because in some states the federal government, rather than the state, will operate the health insurance exchanges.

Texas State Health Commissioner David Lakey, MD, underlined the point that the approach to implementing the law “is very different depending on the state” but also pointed out that the ACA provides benefits for individuals and population health in every community. “Texas will not expand Medicaid coverage and will not open its own exchange,” said Lakey, “but that doesn’t mean that we’re not committed to improving health and healthcare and implementing other parts of the ACA so we can improve health in our state.”  Lakey says in Texas they’ll be using the federal marketplace and are training staff so that their clients can learn about health insurance opportunities.

Even when the ACA is fully implemented, though, Texas would still see 12 percent of its citizen’s uninsured—those include undocumented immigrants and people who choose not to buy coverage.

Significantly, Lakey pointed out, “there is a perception that insurance is the only issue.” To the contrary, Lakey said, “insurance does not take away the important role public health plays in the U.S.”

Lakey also told the conference attendees that the CDC’s budget has gone down 18 percent from 2010, the lowest level since 2003, which reduces its funding ability to help prevent diseases and injury. More education is needed on the value of public health to help prevent further detrimental cuts.

Barbara Ferrer, PhD, director of the Boston Public Health Commission, spoke to the community benefit requirements under the ACA, which offers an opportunity for public health departments to work with hospitals around community health improvement. Community benefit activities include a community health assessment to identify critical health needs and drive targeted investments in the community.

In Boston, which has had a community benefit requirement for over a decade, collaborative efforts among the health department, hospitals and other groups, was able to identify adult asthma in subsidized housing units as a critical health issue in 2006 and found that house pests were in part responsible. Using a one on one approach with home visits by nurses, four years later the asthma rates for subsidized housing were similar to the rates for homes that were not subsidized.

Ferrer pointed out some health department gaps that need closing for maximum benefit from ACA public health initiatives including IT needs for data collection requirements and the need to build strategic partnerships. Ferrer added that health departments will also need to figure out “how we’ll demonstrate a return on investment.”

Demonstration projects discussed at the session include one in Crook County, Oregon, which has placed public health nurses in one obstetrics practice for teaching purposes.

“Public health, like politics, is ultimately local, said Muriel DeLaVergne-Brown, director of the Crook County health department. “I decided I won the battle…when a friend at a hospital told me at meetings she has my voice in her head that says ‘don’t forget public health,’” she said.

In Chicago, Bechara Choucair, MD, the city’s health commissioner, says they have just over 500,000 uninsured adults and that they are working with a lot of partners to “find those people…so we can target our enrollment efforts.” Choucair added that 94 percent of the businesses in Chicago are small businesses employing fewer than 15 employees, and they are working to make sure their employees are connected to the marketplace.

Choucair also told the attendees, many of them just learning about opportunities for communities from hospital community benefit requirement , that Chicago hospitals invest $1 billion in community benefit every year, “and we want to be sure it’s aligned with our goals,  and we’ve been successful to some degree.”

>>Bonus Link: NACCHO has several resources for local health departments on implementing the Affordable Care Act and the law’s provisions for public health.

This commentary originally appeared on the RWJF New Public Health blog.