Navigating A Minefield: TB Control In Uncertain Times CTCA 2011 Conference Health Care Reform Mary A. Pittman, DrPH President & CEO Public Health Institute April 28, 2011

History of Health reform in US

Theodore Roosevelt argued that a mandatory program of health insurance to protect people against the costs of unexpected illness and job loss would prove worthwhile because the program would prevent sickness from driving people to the poor house and motivate everyone to adopt a healthier lifestyle. 1912

Franklin D. Roosevelt Signed Social Security into law after removing health coverage from the package because of strong opposition by organized medicine. 1935

After President Roosevelt’s unexpected death, President Harry Truman attempted to revive health coverage in his “Fair Deal”. He got little support His plan was also labeled as “socialized medicine” by the AMA.

President Lyndon Johnson won by a landslide and pushed to create health coverage for seniors (Medicare) and health insurance for the indigent (Medicaid). 1965

Senator Edward Kennedy first introduced his “Health Security Act” in President Clinton unveiled the “Health Security Act”, created after 10 months of work by 34 working groups, but it was long, (>1,400 pages) and complex

The AFFORDABLE CARE ACT signed into law by President Barack Obama. March 23, 2010

The Affordable Care Act 2010 ACA titles Controversial areas Populations covered

ACA Titles TITLE I − QUALITY, AFFORDABLE HEALTH CARE FOR ALL –Immediate Improvements in Health Care Coverage for All Americans –Immediate Actions to Preserve and Expand Coverage –Quality Health Insurance Coverage for All Americans –Part I − Health Insurance Market Reforms –Part II − Other Provisions- coverage choice and shared responsibility TITLE II − ROLE OF PUBLIC PROGRAMS –Medicaid –Enhanced Support for the Children's Health Insurance Program –Medicaid and CHIP Enrollment Simplification –Improvements to Medicaid Services – New Options for States to Provide Long-Term Services and Supports –Medicaid Prescription Drug Coverage –Medicaid Disproportionate Share Hospital (DSH) Payments –Improved Coordination for Dual Eligible Beneficiaries – Improving the Quality of Medicaid for Patients and Providers – Improvements to the Medicaid and CHIP Payment and Access Commission (MACPAC) –Protections for American Indians and Alaska Natives Subtitle L − Maternal and Child Health Services TITLE III − IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE –Transforming the Health Care Delivery System Part I − Linking Payment to Quality Outcomes Under the Medicare Program Part II − National Strategy to Improve Health Care Quality Part III − Encouraging Development of New Patient Care Models TITLE IV − PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC HEALTH TITLE V − HEALTH CARE WORKFORCE TITLE VI − TRANSPARENCY AND PROGRAM INTEGRITY TITLE VII − IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES TITLE VIII −CLASS ACT TITLE IX − REVENUE PROVISIONS TITLE X − STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS

Areas of Controversy The individual mandate. The prohibition on states to reduce Medicaid eligibility. The employer mandate. The CLASS Act. Funds that could support abortions

Improved Quality and Affordable Care How does this affect the uninsured or underinsured population? 32 million more people are projected to be covered nationwide. 4.7 Million Californians gain coverage CHIS, 2009

Populations Covered Key populations have expanded health care access Adult children up to 26 Elderly, disabled Poor: –133% fed poverty level –200% poverty level –Increased funding for FQHCs

Populations Covered Disproportionately low-income Most uninsured or publically insured Most members of racial/ethnic minority Overlapping populations means increased access to care for many patients at high risk for TB. Source: National Association of Community Health Centers 2010

Who will remain outside ACA coverage? 2.3 Million remain uncovered and will need safety net services in California.

Areas of Opportunity HITECH Prevention measures in ACA Accountable Care Organizations Innovation Fund

HITECH $17B funded by ARRA to enhance electronic health records and to employ meaningful use standards Health Information Exchange

Affordable Care Act – Public Health Public health measures phased in 2010 – 2015 Prevention Trust Fund Information infrastructure Preventive health services Workforce & capacity Community Intervention

Affordable Care Act – Public Health Support Population Based Services Investments in population based and community based prevention, education and outreach programs Prevention Trust Fund: $18B over 10 years National Strategy for Prevention

Affordable Care Act Support Population Based Services Address chronic underfunding of the nation’s public health system Develop, expand and monitor programs to reduce disparities in health Require methods to assess the impact federal policies and programs on have on public health

Affordable Care Act Support Population Based Services Account for the real cost savings and cost avoidance of preventive and early intervention services at the individual and community levels through more accurate fiscal scoring methods

Affordable Care Act Support Population Based Services Establish health goals and outcomes and require an annual “State of the Nation’s Health” report to hold ourselves accountable

Affordable Care Act – Health Care Reform Health Care Coverage and Delivery Comprehensive health care coverage for all Strengthen public programs Access to affordable and high-quality health care for all Accountable Care Organizations First dollar support for evidence-based clinical preventive services Expand public health and preventive care workforce

Covered Preventive Services Covered Preventive Services for Adults –Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked –Alcohol Misuse screening and counseling –Aspirin use for men and women of certain ages –Blood Pressure screening for all adults –Cholesterol screening for adults of certain ages or at higher risk –Colorectal Cancer screening for adults over 50Depression screening for adults –Type 2 Diabetes screening for adults with high blood pressure –Diet counseling for adults at higher risk for chronic disease –HIV screening for all adults at higher risk

Covered Preventive Services Immunization vaccines for adults--doses, recommended ages, and recommended populations vary: –Hepatitis A –Hepatitis B –Herpes Zoster –Human Papillomavirus –Influenza Measles, Mumps, Rubella –MeningococcalPneumococcalTetanus, Diphtheria, Pertussis –Varicella

Covered Preventive Services Obesity screening and counseling for all adults Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk Tobacco Use screening for all adults and cessation interventions for tobacco users Syphilis screening for all adults at higher risk

Covered Preventive Services Immunization vaccines for children from birth to age 18 — doses, recommended ages, and recommended populations vary: –Diphtheria, Tetanus, Pertussis –Haemophilus influenzae type b –Hepatitis A –Hepatitis B –Human Papillomavirus –Inactivated Poliovirus –Influenza –Measles, Mumps, Rubella –Meningococcal –Pneumococcal –Rotavirus –Varicella

Covered Preventive Services Iron supplements for children ages 6 to 12 months at risk for anemia Lead screening for children at risk of exposure Medical History for all children throughout development Obesity screening and counseling Oral Health risk assessment for young children Phenylketonuria (PKU) screening for this genetic disorder in newborns Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk Vision screening for all children Tuberculin testing for children at higher risk of tuberculosis

What will the new public health paradigm look like when health care reform is implemented?

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