American Public Health Association OCTOBER 2010 Prevention Provisions in the Affordable Care Act Gail Shearer, MPP Executive Summary n 2010 Congress enacted the Affordable Care Act, a historic and vigorously debated law designed to dramatically overhaul the health system. Included in the Affordable Care Act are comprehensive prevention provisions consistent with those called for by the American Public Health Association I (APHA) in its health reform agenda and supported by other leading experts in population health and prevention.12 The Affordable Care Act, if it is adequately funded, effectively implemented, and creatively leveraged through public and private-sector partnerships, will mark the turning point in the fundamental nature of our health system, initiating the transformation of our health system from one that treats sickness to one that promotes health and wellness. This issue brief begins (Section III) by summarizing the state of public health in the United States, including some measures of the growth of preventable diseases. Section IV describes the major provisions of the Affordable Care Act that address prevention through: (1) investing in public health; (2) educating the public; (3) expanding insurance coverage and requiring that health insur- ance include recommended preventive benefits; and (4) building capacity for better prevention in the future through demonstrations, research and evaluation. 800 I Street, NW • Washington, DC 20001-3710 • 202-777-APHA • fax: 202-777-2534 • www.apha.org Section V identifies key implementation I. Introduction and issues. Federal, state and local policy makers charged with implementing the Affordable Overview Care Act face challenging issues in the near [Health reform’s] aim is to transform future such as: (1) deciding how to allocate America’s current sick care system into new prevention funds and protect exist- a genuine health care system, one that is ing funds; (2) allocating grants (federal) and focused on keeping us healthy and out of applying for grants (state and local) so that the hospital in the first place.—Senator Tom prevention efforts are coordinated effi- Harkin3 ciently; (3) learning the best ways to ensure Senator Harkin, a long-time leader on the accessibility of available information preventive health care, captures in his quote about the benefits of prevention to both the the hope that the landmark health reform general population and hard-to-reach popu- legislation enacted in 2010 will make lations; and (4) learning how best to com- fundamental changes in our system so that municate with consumers and patients so it prevents disease and promotes wellness. that they act on that information to prevent The Affordable Care Act, signed into law on ealth reform’s aim disease and disability and improve health. March 23, 20104, included comprehensive Successful implementation of the preven- is to transform initiatives that elevate the nation’s commit- tion provisions of the Affordable Care Act ment to preventing disease and promoting America’s current will require the devoted efforts of staff at all wellness. Its provisions cut across a range of H levels of government, of all members of the needs that have been articulated by ex- sick care system into a genu- healthcare and public health professional perts.5 These include the establishment of a ine health care system, one workforce, and of health plans and insurance large Prevention and Public Health Fund, companies. It also will demand the engage- creation of a National Prevention, Health that is focused on keeping us ment of citizens, who will need to be more Promotion and Public Health Council to educated about choices in the health system. coordinate federal prevention initiatives, healthy and out of the hospital Section VI includes recommendations for development of new grant programs to in the first place. policymakers to: (1) leverage health reform fund state and local initiatives at the com- —Senator Tom Harkin3 funding and other existing funding to ex- munity level, a new requirement that health pand total funds for prevention and maxi- insurance policies cover recommended mize progress; (2) conduct research about preventive services, and development and how to communicate prevention messages implementation of a goal-driven strategy most effectively to traditionally under- for prevention that will include a timeline served populations; and (3) improve public for measurable actions. The law also requires health by making comparative effectiveness that changes to insurance coverage and poli- research on prevention a priority and by ex- cy must be guided by scientific evidence, panding successful prevention pilot projects. and calls for evaluations and reports that This issue brief does not cover workforce provide an opportunity to learn from expe- issues such as the expansion of primary care rience and make improvements over time. and community health centers. These im- The American Public Health Association portant areas will be addressed in a separate (APHA) and the public health community forthcoming issue brief. have long supported health reform that ex- pands health insurance coverage to the mil- lions of uninsured Americans and provides The American Public Health Association (APHA) and the public health community have long supported health reform that expands health insurance coverage to the millions of uninsured Americans and provides access to care for all residents. APHA also has supported the creation of a dedicated funding stream for prevention, wellness and public health.6 2 access to care for all residents. APHA also has supported the creation of a dedicated funding stream for prevention, wellness and public health.6 APHA’s 2009 Agenda for Health Reform describes the population- based services needed to help communities and individuals be healthy.4 A number of organizations and coalitions that promote improved public health have taken similar positions.7 The Affordable Care Act addresses many of these recommendations from the public health community and represents a bold step for the nation in creating a system that promotes wellness. This issue brief addresses the provisions in health reform that directly relate to preven- tion. It does not deal with the many indirect he Affordable Care Act addresses recommendations from the public ways that health reform promotes health health community and represents a bold step for the nation in creat- and prevents disease, most notably by reduc- ing the ranks of the uninsured who have T ing a system that promotes wellness. faced financial and access barriers to both acute and preventive care. Nor does it cover workforce issues, such as those related to the the authorized funds are appropriated, but expansion of primary care, the public health also on the ability to achieve changes across workforce, medical homes, and community many non-health care aspects of our society health centers, all of which will play a cru- through healthy environments, education, a cial role in supporting the transformation of more nutritious food supply, and modifica- our health care culture to one that embraces tion of individual behaviors. prevention. After a brief overview of the problem At this time, there is ambiguity in the of inadequate focus on prevention in the law about the extent to which funds are past, this issue brief describes the major authorized and/or appropriated, creating prevention provisions in health reform uncertainty about the precise amounts of and identifies some of the key policy and funding that will actually be available. The implementation issues that lie ahead. For law often uses language such as “there are an implementation timeline of the public authorized to be appropriated such sums as health, prevention and wellness provisions in may be necessary to carry out this section” the Affordable Care Act, see Appendix 1. (Section 4004), and “out of any funds in the Treasury not otherwise appropriated, there II. The Problem are appropriated $1,000,000 for fiscal year Rising rates of preventable disease and 2010 to carry out this subsection” (Section death, as well as international comparisons 4203). Many sections do not include any of health outcome measures, reveal that language about funding, creating uncer- Americans are not as healthy as they could tainty about future funding. The Congres- be, and that they are becoming increasingly sional Budget Office has published a table unhealthy over time. The relatively un- of authorizations subject to appropriation healthy population stems from many factors, in order to clarify which provisions have including but not limited to the health sys- specific dollar amounts authorized (by year) tem. Lack of access to a high-quality educa- and which provisions do not yet have a tion, nutritious food, adequate exercise, specified budget.8 The success of the Afford- and a healthy and safe environment are key able Care Act’s prevention and public health factors driving the diminishing health of the initiatives will depend not only on whether 3 The World Cancer Research Fund and American Institute for Cancer Research found that cancers are principally caused by environmental factors, the most important of which are tobacco, diet, physical activity and exposures in the workplace. Two-thirds of all cancers can be eliminated through changes to diet, physical activity and tobacco use.16 nation. In the absence of other changes, even choices that lead to poor health outcomes a complete transformation of the health sys- are not in fact lifestyle “choices,” but rather tem is not sufficient to significantly alter the the consequences of economic and geo- growing problems of heart disease, obesity graphic factors that restrict or prevent access and cancers that affect our nation’s health. to healthy food and safe environments in Preventable disease and death: Prevent- which to exercise. able disease and death impose a large burden Research has shown that coronary artery in the United States. In 2009, an alarming disease can be reversed with lifestyle changes 26.6 percent of the U.S.