The Affordable Care Act (ACA) and Public Health

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The Affordable Care Act (ACA) and Public Health

• Nate Smith, MD, MPH
• Director and State Health Officer
• Arkansas Department of Health

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Health Outcomes in Arkansas

• Arkansans experience worse health outcomes than
  many other Americans
• 49th in overall health ranking
• Significant racial and geographic disparities
  within Arkansas
• Fundamental inequity

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Infant Mortality Rate
Source National Center for Health Statistics
(NCHS) and Linked Birth/Infant Death Files,
Health Statistics Branch, Arkansas Department of
Health
4
Source Linked Birth/Infant Death Files, Health
Statistics Branch, Arkansas Department of Health
(provisional data)
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Arkansas Red Counties, In Accordance with Act 790
and 798 2009 Life Expectancies at Birth
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ACA and Preventive Health Services

• The ACA will markedly expand first-dollar
  coverage for preventive health services
• USPSTF grade A and B recommendations
• Preventive health services have not been a
  priority
• higher costs
• poorer outcomes
• ACA provides a reimbursement model for ADH and
  others to expand access

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Overview

• The U.S. Preventive Services Task Force
• Makes recommendations on clinical preventive
  services to primary care clinicians
• The USPSTF scope for clinical preventive services
  include
• screening tests
• counseling
• preventive medications
• Services are offered in a primary care setting
• Recommendations apply to adults children with
  no signs or symptoms

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Recommendation Grades

• Letter grades are assigned to each recommendation
  statement. These grades are based on the strength
  of the evidence on the harms and benefits of a
  specific preventive service. http//www.uspreventi
  veservicestaskforce.org/uspstf/grades.htm

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Recommendation Grid
Net Benefit
Quality of Evidence Substantial Moderate Small Zero/ Negative
Good A B C D
Fair B B C D
Poor I
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ACA Coverage of Preventive Health Services

• Group health plans and health insurance issuers
  offering group or individual health insurance
  coverage shall, at a minimum provide coverage for
  and shall not impose any cost sharing
  requirements for
• Evidence-based items or services that have a
  rating of A or B in the current
  recommendations of the USPSTF
• Immunizations recommended by the Advisory
  Committee on Immunization Practices (ACIP) of the
  CDC
• Evidence-informed preventive care and screenings
  for infants, children and adolescents provided
  for in the comprehensive guidelines supported by
  the Health Resources and Services Administration
  (HRSA)

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Guidelines for Womens Preventive Services

• Additional preventive care and screenings not
  described in paragraph (1) as provided for in
  comprehensive guidelines supported by HRSA
• Well-woman visits
• Support for breastfeeding equipment
• Contraception
• Domestic violence screening and counseling

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Healthcare Access Issues

• Access issues will remain in many rural areas
• Lack of primary care providers in many rural
  areas
• Innovative strategies to expand access under the
  ACA
• Utilizing mid-level providers (Advanced Practice
  Nurses, Physician Assistants)
• Community health workers
• Telemedicine to provide specialty evaluation and
  follow up
• ADH has Local Health Units with telehealth
  equipment in all 75 counties and may help improve
  access

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Determinants of Health
Michael D. Warren, MD MPH FAAP, Tennessee Dept.
of Health 2013 Amos Christie Lecture
Environment 5

• Health care contributes a small amount to an
  individuals overall health and well-being
• Improving Health requires comprehensive focus

HealthCare 10
Health Behaviors 40
Social Factors 15
Genetics 30
Sources McGinnis JM Foege WH. Actual causes of
death in the United States. JAMA 1993
270(18)2207-12 (Nov 10)McGinnis JM,
Williams-Russo P, Knickman JR. The case for
more active policy attention to health promotion.
Health Affairs 2002 21(2)78-93 (Mar).
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Health ? Health Insurance

• Population health outcomes are largely determined
  outside the healthcare setting
• Environmental factors
• environmental exposures
• safe food water
• built environment
• Social determinants of health
• poverty
• education
• social norms

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• Lifestyle choices
• physical activity
• food choices
• use of tobacco, alcohol and other substances
• Healthcare access
• coverage
• available providers
• transportation
• healthcare seeking behaviors
• The ACA will help to improve individual health
  but will not be sufficient in itself to change
  population health.

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Beyond the ACA

• The Mission of the ADH
• Helping Arkansans improve their own health
• Protecting the public from epidemics
• Providing preventive health services in your
  communities