NACo is pleased to present

Promoting County Public Health: Prevention and Wellness in Health Reform

April 21, 2011

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Webinar Agenda

SpeakersDara Alpert LiebermanGovernment Relations ManagerTrust for America’s Health

Eli BriggsSenior Government Affairs SpecialistNational Association of County and City Health Officials

Promoting County Public Health: Prevention and

Wellness in Health Reform Dara Alpert Lieberman

Government Relations ManagerTrust for America’s Health

National Association of Counties Webinar SeriesApril 21, 2011

Overview About Trust for America’s Health

Why focus on prevention?

What’s in the Affordable Care Act with a special focus on public health, prevention, and wellness provisions?

Looking forward – The future of the new health reform law

About TFAH: Who We Are Trust for America’s Health (TFAH) is a non-profit, non-partisan

organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.

Why Focus on Prevention? Actions that precede coverage are key factors in public health -

Achieving good health outcomes requires healthy communities, not just healthy individuals

Chronic disease can be effectively prevented in the community as opposed to managed in the health care setting – Mitigating the drivers of health care costs is a critical policy outcome

Disparities in chronic conditions are related to the disparities existing in the “health” of communities. Factors include: Poverty, race/ethnicity and obesity Poor communities provide less support for healthy lifestyles (nutrition,

physical activity)

Support for Investing in Prevention is Broad

Should Invest More(Strongly)

Should Invest More (Total)

Should NOT invest more

Total 44 71 22Democrats 60 85 13

Independents 39 68 25Republicans 32 59 32

Northeast 42 72 25Central 45 69 25South 45 73 21West 45 71 21Men 44 71 24

Women 45 72 21

Prevention in CommunitiesQuestion: Are there community-level interventions that could reduce chronic disease levels – and thus affect the biggest driver of increased disease, disability, and cost?

Strategic investment in proven community-based prevention programs can see a return on investment. Savings can be shown by payer – with private payers and Medicare the biggest “winners.”

Yes. Regardless of chronic condition targeted, most interventions fell into 4 categories: physical activity, nutrition, obesity, and smoking cessation

Addressing issues in these 4 categories results in reduced or delayed incidence of disease; mitigation of disease

Stronger Public Health System ACA has implications for public health: Workforce Infrastructure Preparedness Clinical-Community Connections Services to Uninsured Public Health and Prevention Research

Vast Expansion of Coverage Anticipated coverage of 94% of population Expansion of Medicaid to all up to 133% of FPL

Initial 100% federal match in 2014-16; state option earlier Guaranteed issue of health insurance (and mandate

to have it) for all (2014) Subsidies up to 400% of poverty – covering both

premiums and cost sharing Pre-existing Condition Insurance Plan

Immediate access to subsidized insurance for people who have been denied coverage due to a pre-existing condition

Health Insurance Exchanges New entity intended to create a more organized and competitive

market for health insurance by: Offering a choice of plans

Establishing common rules regarding the offering and pricing of insurance

Providing information to help consumers better understand the options available to them

State residents would receive access to more options for better quality affordable health insurance

States would further benefit from decreased uninsured population

Resources to help states implement exchanges announced January, 2011

Coverage Doesn’t = Access Expansion of the safety net

$11 billion over 5 years for expansion of community health centers

Major investment in healthcare workforce $250 million from Prevention and Public Health Fund in

FY 2010 Improved (temporary) reimbursement for Medicaid

providers to Medicare rates

Quality Improvement Major investment in comparative

effectiveness research Major investment in Health Information

Technology Implications for surveillance and for measuring

quality of care Prevention Fund investment in health reform

surveillance

Key Provisions - Clinical Prevention First dollar coverage of clinical preventive services Over time in private insurance; immediate in Medicare and

Medicaid Annual wellness visit in Medicare

U.S. Preventive Services Task Force and the Advisory Committee on Immunization Practices (ACIP)

“Essential Health Benefits” requirements Tobacco cessation for pregnant women

CHIPRA childhood obesity demonstration projects ($25 million)

National Prevention and Health Promotion Strategy National Prevention, Health Promotion and Public

Health Council Chaired by Surgeon General

HHS, HUD, USDA, ED, FTC, DOT, DOL, DHS, EPA, ONDCP, DPC, Asst. Secretary for Indian Affairs

Others: VA, DOD

Health in all policies Due March 23, 2011 External advisory group

National Prevention and Health Promotion Strategy Purposes: (1) set specific goals and objectives for improving the health

of the U.S. through federally-supported prevention,health promotion, and public health programs, consistent withongoing goal setting efforts conducted by specific agencies;

(2) establish specific and measurable actions and timelinesto carry out the strategy, and determine accountability formeeting those timelines, within and across Federal departmentsand agencies; and

(3) make recommendations to improve Federal effortsrelating to prevention, health promotion, public health, andintegrative health care practices to ensure Federal efforts areconsistent with available standards and evidence

Draft National Prevention Strategy Achieve significant gains in life expectancy at

birth and at age 65 within a generation Healthy Communities – where people live, learn,

work, and play Preventive Clinical and Community Efforts Empowered Individuals

Focus on elimination of health disparities Mental and emotional wellbeing

Purpose and Use Purpose: To provide for expanded and

sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public sector health care costs

Use: For prevention, wellness, and public health activities, including: prevention research and health screenings and initiatives, such as the Community Transformation Grant program, the Education and Outreach Campaign for Preventive Benefits, immunization programs

Prevention and Public Health Fund

PPHF: Sustained Funding Prevention and Public Health Fund: $15 billion in mandatory

funding over 10 years (permanent authorization at $2 billion a year)

Supports new and existing prevention and public health programs, including Community Transformation Grants

$500 million available immediately (FY 2010); $750 million available in FY 2011

Separate fund for Community Health Centers ($11 billion over 5 years)

PPHF: Sustained Funding Funding levels:

FY 2010 - $500 million

FY 2011 - $750 million

FY 2012 - $1 billion

FY 2013 - $1.25 billion

FY 2014 - $1.5 billion

FY 2015 and each fiscal year thereafter- $2 billion

Looking Forward - FundingWhat can be funded? Community Prevention, such as Community Transformation

Grants Public Health Infrastructure/Capacity New skills associated with policy change and community

prevention Accreditation

Building the Evidence Base Community Guide and USPSTF Public Health Services and Systems Research

Workforce

True community-based prevention

Community Transformation Grants Requires detailed plan for policy, environmental,

programmatic and infrastructure changes to promote healthy living and reduce disparities Create healthier school environments, including healthy

food options, physical activity opportunities, promotion of healthy lifestyles

Develop and promote programs targeting increased access to nutrition, physical activity, smoking cessation and safety

Highlight healthy options at restaurants and food venues NOT limited to chronic diseases or one disease at a time

What might CTGs look like? Examples of policy and structural change

High impact efforts to make healthy choices easier Sustainable over time

Eligibility: State and local government, national networks of CBOs, and local CBOs

Expectations: Demonstrated ability to bring together a coalition Have or use grants to build policy development capacity Inclusion of state/local public health agencies in coalitions

CTGs (and Prevention Fund) push us to think across silos Physical activity: obesity, diabetes,

cardiovascular disease, depression, injury, school performance, STDs in young people

Anti-bullying: suicide prevention, HIV/STD prevention

Other Prevention Opportunities Directs HHS Secretary to award grants to states to carry out

initiatives to provide incentives to Medicaid beneficiaries who successfully participate in a healthy lifestyle program and demonstrate changes in health risk and outcomes (announced in April)

CHIPRA 2009 Obesity Demonstration Project CHIPRA established a Childhood Obesity Demonstration

Project and authorized $25 million for FY 2009-2013 The Act appropriates $25 million for the Secretary to carry

out the demonstration project in FY 2010 – FY 2014

Building Public Health WorkforceWorkforce (Authorizations): Loan repayment program for public health workers Training for mid-career public health workers Fellowships Epidemiology-Lab Capacity Grants Elimination of cap on Commissioned Corps

Establishment of a Ready Reserve Grants for community health workers

The challenges in a changing political climate…. Legislative and legal challenges to reform Legislative challenges to the Prevention Fund Making the case for prevention: ROI from community prevention Messaging about healthy choices vs. nanny state

Continuing to build the evidence base “Valuing” prevention Success stories

What’s happening over the next year?

Development of National Prevention and Health Promotion Strategy – April 2011 release

Initial convening of Advisory Group (April) Defense of Prevention Fund for FY 2012

budget Maintain vigilance against attempts to defund,

redirect, or cut such funds

Lessons for Policymakers Making healthy choices the easy choices can improve health

and reduce costs The annual discretionary appropriations process and the

Prevention and Public Health Fund provide opportunities to fund community prevention

Communities (public and private sectors) have a responsibility to seize upon this opportunity to promote community prevention – so the exercise of personal responsibility is a viable option

Leadership must come from more than the public health community, and include the public and private sectors

Thank you!

For further information

www.healthyamericans.org/health-reform

dlieberman@tfah.org

The National Connection for Local Public Health

Promoting County Public Health: Prevention and

Wellness in Health Reform

Eli Briggs, Government Affairs Specialist

April 21, 2011

THE BIG PICTURE

The Patient Protection and Affordable Care Act (ACA) sets the stage for a comprehensive national approach to population-based prevention.

• Health in all policies through a National Prevention Strategy

• Recognition of policy and environmental change approaches to public health

• Mandatory appropriation (new money)

FY11 Prevention and Public Health Fund

Community Prevention ($298 million)

• Community and State Prevention ($222 million)

Community Transformation Grants ($145 million) and

Consolidated Chronic Disease Grants ($52.2 million)

• Tobacco Prevention ($60 million)

• Obesity Prevention and Fitness ($16 million)

FY11 Prevention and Public Health Fund

Public Health Infrastructure and Training ($137 million)

• Public Health Infrastructure ($40 million)

Support state, local, and tribal public health infrastructure to advance health promotion and disease prevention through improved information technology, workforce training, and policy development.

• Public Health Workforce ($45 million)

• Public Health Capacity ($52 million) (epidemiology and lab)

FY11 Prevention and Public Health Fund

Clinical Prevention ($182 million)

• Wellness and Preventive Health Services ($112 million) Increase awareness of new preventive benefits made available by ACA. Expand immunization services and activities ($100 million)

• Behavioral Health Screening and Integration with Primary Health ($70 million)

FY12 President’s Budget – Prevention & PH Fund

FY11 FY12 (proposed)

NACCHO Request

National Public Health Improvement Initiative

$40 M $40 M $50 M

CommunityTransformation Grants

$145 M $221 M $221 M

Comprehensive Chronic Disease

$52.2 M $158 M ($705 M

total)

$705 M

Workforce $45 M $25 M ($73 M total)

$73 M

Other Funding Opportunities

President’s Budget FY12HIV Prevention - $343 million for eligible Health Departments

• Reducing HIV incidence

• Increasing linkage to quality care and retention in care of previously diagnosed individuals

• Reducing health disparities

Other Future Funding Opportunities

President’s Budget FY12Teen Pregnancy Prevention - $110 million (Asst. Secy for

Health)

These funding supports competitive grants to public and private entities to fund medically accurate and age appropriate programs that reduce teen pregnancy and for the Federal costs associated with administration and evaluation.

Other Future Funding Opportunities

Community Health Centers

$3.3 billion in FY12 Pres. Budget

CHCs received $11 billion in funding from ACA. Some of this money has already gone out in new and expanded grants.

Challenges to Future Funding

Continuing Resolution funds government programs through September 30

• $158 billion in discretionary funding for Labor-Health and Human Services-Education programs

• $5.5 billion (3%) less than the FY 2010 levels

• CDC cut by $730 million, of which approximately $380 million is unallocated. $100 million is assumed to come from “administrative savings” internal to CDC

The Big Question

Question:

Is Health Reform a Threat or an Opportunity for Local

Health Departments?

Answer:

Yes.

New Roles and Functions to Consider

• Expanded role in Medicaid enrollment and in outreach and enrollment for state health insurance exchanges

• Expanded role in case management.

• Maintain and enhance role as health data and information experts for the community.

New Roles and Functions to Consider

• Collaborate with non-profit hospitals to conduct community health needs assessments required by IRS.

• Develop new business models to bill or contract for services.

• Leverage the dollars flowing to FQHC’s by developing a public entity FQHC.

New Partnerships to Consider

• Convene partnerships for population-based prevention, including the engagement of new partners in policy development.

• Pursue relationships with groups forming Accountable Care Organizations.

• Establish new arrangements with FQHC’s for co-location of services, referrals, and/or purchase of services.

Some Questions to Ask

When more health department clients have insurance cards in hand, what will be the impact on financing and mix of clinical and population-based services in my community?

Should I plan to transition clinical services to other providers and focus more resources on population-based prevention?

Local Health Department Challenges

• Lack of community support for health system reform.

• Lack of State willingness or capacity to implement Affordable Care Act.

• Possible influx of new patients to health care systems with inadequate reimbursement or resources (particularly PCPs) to care for them.

Local Health Department Challenges

• Viability as a safety net provider.

• Inability to compete as other entities assume greater roles in prevention and primary care.

• Future funding reductions for public health services erroneously deemed unnecessary by policy makers when expanded health insurance coverage is in place.

Local Health Department Challenges

• Realigning resources for altered roles.

• Training the current public health workforce for altered roles.

• Pursuing new opportunities after years of cuts have weakened the public health system.

NACCHO Resources

A webpage with resources that we are populating as fast as we can:

http://www.naccho.org/advocacy/healthreform.cfm

Eli Briggs

ebriggs@naccho.org; 202-507-4194

Other Resources

White House: http://www.whitehouse.gov/HealthReform

Department of Health and Human Services: http://www.healthcare.gov/

Kaiser Family Foundation: http://healthreform.kff.org/

Families USA: http://www.familiesusa.org

To learn more about and register to attend NACo’s 2011 Annual Conference

in Multnomah County, OR July 15-19

Please visit www.naco.org/meetings

For questions about NACo’s Health Reform Implementation webinars, contact Anita Cardwell at acardwell@naco.org

To send health reform implementation questions or sign up for updates, email:healthreforminfo@naco.org

and for more information visit:www.naco.org/healthreformimplement

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