What If? Public Health Services At Risk With or Without the ACA

State of Reform is proud to launch, in collaboration with the Univ of Washington School of Public Health – Health Policy Center Initiative , a series titled “What If: A Post-Supreme Court World.”  This is the second piece in a series of contributions hosted on our news site, by a range of authors, about the possibilities for health care in a still hypothetical world after a Supreme Court decision.

State and local public health agencies overall were very enthusiastic about passage of the ACA: its promise to reduce the number of uninsured, the mention of prevention in many of its provisions, and the considerable funding it provides through the Prevention and Public Health Fund. As things have worked out, many health departments will find themselves struggling to deliver core public health services regardless of the Supreme Court’s decision – that is, with or without the ACA.

Why are public health agencies on shaky ground? They’ve been hit hard with budget cuts over the past few years. According to the National Association of County and City Health Officials, local public health agencies have cut almost 40,000 positions since 2008. During 2011, 57% reduced or eliminated at least one program. And there is considerable uncertainty about whether accountable care organizations and hospitals, charged by the ACA with taking on community health assessments and preventive services, have the skills, staffing, or commitment to do this. The real risk is that with or without the ACA, we may find many communities with no one providing the population-based services that benefit everyone.

In a March 1, 2012, post on Health Affairs blog, Dr. Georges Benjamin, Executive Director of the American Public Health Association, decried the cuts and diversions that have occurred to the Prevention and Public Health Fund. Calling the Fund “the prevention cornerstone” of the ACA, he observed: “While some monies from this fund have already been invested to support local prevention and public health initiatives, our hopes for an appropriate and full transformation toward population health may be slipping away.”

Of course, it might all work out. The most optimistic scenario: The ACA is affirmed; the Prevention and Public Health Fund is fully funded; raiding of the Fund for non-public health activities ceases and public health agencies receive significant flexible funding; and accountable care organizations take seriously their mandates to conduct community health assessments and invest in a broad range of community prevention activities. In this scenario, communities benefit and public health agencies are strong and effective.

Another possible – albeit bleaker – scenario: The ACA is affirmed; the Prevention and Public Health Fund is partially funded; raiding of the Fund is reduced and public health agencies receive some flexible funding; and some accountable care organizations take the ACA mandates seriously. Some communities would likely benefit, and many public health agencies would be functional…though strained.

A third – maybe wishful – scenario assumes that even if the ACA is overturned, the genie has been let out of the bottle: that is, experience to date with the ACA and discussions about its implementation have raised awareness and generated ideas about better coverage, prevention, and cost-effectiveness throughout the health system. The momentum is there and there’s even an inevitability that states or communities will take on these issues. Most communities would eventually benefit. Public health agencies likely would change services and shape to become partners with health care organizations. But such beneficial outcomes would come only after a period of great challenge…and even chaos.

Finally, there is the scenario that could happen with or without the ACA: Public health agencies continue to lose funding and have further reduced ability to address the health of their communities; health care organizations continue to do pretty much what they do now; and population and preventive health programs that once had the promise of increased attention and support through the ACA are marginalized or dismantled. In this scenario, “health” loses big-time. Unfortunately, there are too many signs that this may be the most likely scenario, unless we do something about it.

Susan Allan can be reached via email at info@stateofreform.info.

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