Improving the Population's Health: The Affordable Care Act and the Importance of Integration

Patient Protection and Affordable Care Act, Pub. L. No. 111–148, 124 Stat. 119.

Schroeder S. A. , “We Can Do Better – Improving the Health of the American People,” New England Journal of Medicine 357, no. 12 (2007): 1221–1228, at 1222 (noting that inadequate health care services account for only 10 percent of risk of premature mortality).

Atwood K. Colditz G. A. Kawachi I. , “From Public Health Science to Prevention Policy: Placing Science in Its Social and Political Contexts,” American Journal of Public Health 87, no. 10 (1997): 1603–1606, at 1603.

For example, see Booske B. C. Athens J. K. Kindig D. A. Park H. Remington P. L. , Different Perspectives for Assigning Weights to Determinants of Health, University of Wisconsin Population Health Institute, County Health Rankings Working Paper, 2010, at 6

(citing studies estimating effect at 12% or 21%)

Robert Wood Johnson Foundation, Beyond Health Care: New Directions to a Healthier America, Recommendations from the Commission to Build a Healthier America, 2009, at 10 (estimating the effect at 10–15%).

Rundall T. G. , “The Integration of Public Health and Medicine,” Frontiers of Health Service Management 10, no. 4 (1994): 3–24, at 15.

Stanton M. W. , The High Concentration of U.S. Health Care Expenditures, Agency for Healthcare Research and Quality Research in Action 19 (2006): 1–9, at 6, available at <http://www.ahrq.gov/research/ria19/expendria.pdf> (last visited May 15, 2011).

Brouwer W. Van Exel J. Van Baal P. Polder J. , “Economics and Public Health: Engaged to Be Happily Married!” European Journal of Public Health 17, no. 2 (2006): 122–123.

Shi L. , “Public Health, Medical Care, and Mortality Rates,” Journal of Health Care for the Poor and Underserved 6, no. 3 (1995): 307–321.

Id., at 307. Comparison across states also shows a lack of correlation between levels of medical expenditure and health outcome measures.

See Rundall, supra note 5, at 9.

Id., at 10.

Mokdad A. H. Marks J. S. Stroup D. F. Gerberding J. L. , “Actual Causes of Death in the United States, 2000,” JAMA 291, no. 10 (2004): 1238–1242, at 1238. Analyzing mortality data reported to the Centers for Disease Control, the authors found that modifiable behavior caused approximately 951,000 out of 2,400,000 total deaths in 2000.

Id., at 1240, table 2 (finding that tobacco contributed to 435,000 deaths, poor diet and inadequate activity to 365,000, alcohol to 85,000, motor vehicle accidents to 43,000, firearms to 29,000, risky sexual behavior to 20,000, and illicit substance abuse to 17,000).

For example, see Peterson D. E. Zeger S. L. Remington P. L. Anderson H. A. , “The Effect of State Cigarette Tax Increases on Cigarette Sales,” American Journal of Public Health 82, no. 1 (1992): 94–96.

See generally Booske et al., supra note 4, at 4, noting that a comprehensive literature review reveals that social and environmental circumstances account for 28% of health outcomes, whereas health care accounts for only 14%.

Srinivasan S. O'Fallon L. R. Dearry A. , “Creating Healthy Communities, Healthy Homes, Healthy People: Initiating a Research Agenda on the Built Environment and Public Health,” American Journal of Public Health 93, no. 9 (2003): 1446–1450, at 1446.

See also Khan F. , “Combating Obesity through the Built Environment: Is There a Clear Path to Success?” Journal of Law, Medicine & Ethics 39, no. 3 (2011): 387–393.

Gostin L. O. Boufford J. I. Martinez R. M. , “The Future of the Public's Health: Vision, Values, and Strategies,” Health Affairs 23, no. 4 (2004): 96–107, at 107 note 29 (citing studies relating to the built environment)

Centers for Disease Control and Prevention, “Ten Great Public Health Achievements – United States, 1900–1999,” Morbidity and Mortality Weekly Report 48, no. 12 (1999): 241–248, at 241, available at <http://www.cdc.gov/mmwr/PDF/wk/mm4812.pdf> (last visited June 22, 2011) (noting that 25 years of a 30-year increase in average lifespan was attributable to public health measures).

In 2000, exposure to microbial or toxic agents resulted in 130,000 deaths. See Mokdad ., supra note 12, at 1240 table 2.

For a more detailed discussion of the importance of public health, see Gostin L. O. Jacobson P. D. Record K. L. Hardcastle L. E. , “Restoring Health to Health Reform: Integrating Medicine and Public Health to Advance the Population's Well-Being,” University of Pennsylvania Law Review 159 (2011): 101–147.

Brandt A. M. Gardner M. , “Antagonism and Accommodation: Interpreting the Relationship between Public Health and Medicine in the United States during the 20th Century,” American Journal of Public Health 90, no. 5 (2000): 707–715, at 708.

Axelsson R. Axelsson S. B. , “Integration and Collaboration in Public Health: A Conceptual Framework,” International Journal of Health Planning and Management 21, no. 1 (2006): 75–88, at 78.

See Brandt Gardner , supra note 20, at 708.

Kushner R. F. , “Barriers to Providing Nutrition Counseling by Physicians: A Survey of Primary Care Practitioners,” Preventive Medicine 24, no. 6 (1995): 546–552, at 551 (finding that low reimbursement rates incentivize physicians to spend five or fewer minutes discussing the importance of nutrition with patients).

Hospital Survey and Construction Act, ch. 958, 60 Stat. 1040 (1946).

McGinnis J. M. , “Can Public Health and Medicine Partner in the Public Interest?” Health Affairs 25, no. 4 (2006): 1044–1052, at 1048.

Gruber J. , “A Win-Win Approach to Financing Health Care Reform,” New England Journal of Medicine 361, no. 1 (2009): 4–5, at 4.

Breton M. Levesque J. F. Pineault R. Lamothe L. Denis L. J. , “Integrating Public Health into Local Healthcare Governance in Quebec: Challenges in Combining Population and Organization Perspectives,” Healthcare Policy 4, no. 3 (2009): 159–178, at 169.

Leischow S. J. Milstein B. , “Systems Thinking and Modeling for Public Health Practice,” American Journal of Public Health 96, no. 3 (2006): 403–405, at 404.

Id., at 404.

See Rundall , supra note 5, at 15.

Brooks R. G. Beitsch L. M. Street P. Chukmaitov A. , “Aligning Public Health Financing with Essential Public Health Service Functions and National Public Health Performance Standards,” Journal of Public Health Management Practice 15, no. 4 (2009): 299–306

Atchison C. Barry M. A. Kanarek N. Gebbie K. , “The Quest for an Accurate Accounting of Public Health Expenditures,” Journal of Public Health Management Practice 6, no. 5 (2000): 93–102.

Id. (Brooks et al.), at 299.

St-Pierre M. Reinharz D. Gauthier J. B. , “Organizing the Public Health-Clinical Health Interface: Theoretical Bases,” Medicine, Health Care and Philosophy 9, no. 1 (2006): 97–106, at 99.

For example, see Abrams D. B. Orleans C. T. Niaura R. S. Goldstein M. G. Prochaska J. O. Velicer W. , “Integrating Individual and Public Health Perspectives for Treatment of Tobacco Dependence Under Managed Care: A Combined Stepped-Care and Matching Model,” Annals of Behavioral Medicine 18, no. 4 (1996): 290–304.

See Brandt Gardner , supra note 20, at 712.

See St-Pierre ., supra note 33, at 99.

Hemenway D. , “Why We Don't Spend Enough on Public Health,” New England Journal of Medicine 362, no. 18 (2010): 1657–1658, at 1657.

For example, see Cherry R. A. , “Repeal of the Pennsylvania Motorcycle Helmet Law: Reflections on the Ethical and Political Dynamics of Public Health Reform,” BMC Public Health 10 (2010): 202–205.

See Sensenig A. L. , “Refining Estimates of Public Health Spending as Measured in National Health Expenditures Accounts: The United States Experience,” Journal of Public Health Management 13, no. 2 (2007): 103–14, at 108 table 1.1 (reporting that public health represented three percent of total health expenditures in 2004).

For example, see Levi J. St. Laurent R. Segal L. M. Vinter S. , Shortchanging America's Health: A State-by-State Look at How Public Health Dollars Are Spent and Key Health Facts, 2010, at 1, available at <http://healthyamericans.org/assets/files/shortchanging09.pdf> (last visited June 22, 2011) (finding that federal public health spending has not changed in the last five years and state governments have recently cut spending).

The Clinical Preventive Services Task Force (under the Agency for Healthcare Research and Quality) is charged with developing recommendations regarding the efficacy of clinical preventive services. ACA § 4003(a), 124 Stat. 119, 541–42.

The Department of Health and Human Services' Advisory Group on Prevention, Health Promotion, and Integrative and Public Health will advise the National Prevention, Promotion, and Public Health Council, chaired by the Surgeon General. The Council is in the process of developing a National Prevention Strategy and will issue recommendations to Congress by 2011. Id. § 4001, 124 Stat. at 538–41.

See St-Pierre ., supra note 33, at 97.

U.S. Department of Health and Human Services, Building Healthier Communities by Investing in Prevention, available at <http://www.healthcare.gov/news/factsheets/prevention02092011b.html> (last visited June 22, 2011).

The Fund is the first guarantee of federal monies appropriated towards prevention on an annual basis. The amounts, however, are nominal: 1.5 billion dollars in the fiscal year 2014 and two billion per annum thereafter, ACA § 4002(b), 124 Stat. at 541. In contrast, estimates indicate that annual funding of $4.3 billion is necessary merely to sustain support for public health activities, while the cost of a modernized system is estimated at $18 billion annually ( Levi J. Juliano C. Richardson M. , “Financing Public Health: Diminished Funding for Core Needs and State-by-State Variation in Support,” Journal of Public Health Management & Practice 13, no. 2 [2007]: 97–102, at 100).

ACA § 4201(f), 124 Stat. at 566; id. § 4002(b), 124 Stat. at 541.

Shortly after President Obama signed the ACA into law, Senators Johanns and Thune introduced an amendment to divert $11 billion from the Prevention Fund into the general federal budget to compensate for lost tax revenue that would have resulted from the proposed repeal of small business tax reporting requirement. Small Business Paperwork Mandate Elimination Act, S.3578, 111th Cong. (2010).

Koh H. K. Sebelius K. G. , “Promoting Prevention through the Affordable Care Act,” New England Journal of Medicine 363, no. 14 (2010): 1296–1299, at 1297.

ACA § 4108, 124 Stat. at 561–64.

ACA § 4201, 124 Stat. at 564–66.

See U.S. Department of Health and Human Services, supra note 44.

Beitsch L. M. Brooks R. G. Glasser J. H. Coble Y. D. , “The Medicine and Public Health Initiative: Ten Years Later,” American Journal of Preventive Medicine 29, no. 2 (2005): 149–153, at 150.

Id., at 150.

Oliver T. R. , “The Politics of Public Health Policy,” Annual Review of Public Health 27 (2006): 195–233, at 195.

Although there is a grant program to fund the implementation of efficacious strategies, this program focuses only on implementing preventive strategies from the federal task force, not the state demonstration projects. It is also given meager funding.

Qualified health plans include those participating in state-based exchanges immediately, and all group plans by 2014. States cannot impose cost-sharing for annual check-ups on any Medicaid beneficiaries, and must also cover smoking cessation services free of charge for pregnant women immediately and for all beneficiaries by 2014. While states are not required to eliminate cost-sharing for other preventive services, they will receive a one percent increase in federal medical assistance for doing so. ACA § 4107, 124 Stat. at 560–61.

As of 2008, fewer than 30 percent of private sector employers offered wellness incentives to employees, even though for every dollar spent on a wellness promotion, employers save approximately five times as much on health care costs and lost productivity. See Stolzfus E. R. , Access to Wellness and Employee Assistance Programs in the United States, Bureau of Labor Statistics, 2009, at charts 2–3, available at <http://www.bls.gov/opub/cwc/cm20090416ar01p1.htm> (last visited June 22, 2011)

(showing that 25 percent of all private sector workers had access to wellness programs in 2008)

U.S. Department of Health and Human Services, Prevention Makes Common “Cents,” U.S. Department of Health and Human Services, 2003, at 23, available at <http://aspe.hhs.gov/health/prevention/prevention.pdf> (last visited June 22, 2011)

(noting a study of nine large private employers that found their health promotion and disease management programs “with the range of benefit-to-cost ratios, ranging from $1.49 to $4.91 in benefits per dollar spent on the program”).

The ACA authorizes the Department of Health and Human Services, Department of the Treasury, or the Secretary of Labor to increase the incentive valuation cap to up to 50 percent of the value of the plan. Federal wellness program grants will distribute $200 million between 2011 and 2015 to employers with fewer than a hundred employees. ACA § 10408, 124 Stat. at 977–78.

Navarro V. , “What We Mean by Social Determinants of Health,” International Journal of Health Services 39, no. 3 (2009): 423–441, at 424, where the author cites evidence that in East Baltimore, a black unemployed youth has a lifespan 32 years shorter than a white corporate lawyer, and a blue-collar worker is 2.8 times more likely than a businessman to die from a cardiovascular condition.

Gruber J. , The Role of Consumer Copayments for Health Care: Lessons from the RAND Health Insurance Experiment and Beyond, 2006, at 6, available at <http://www.kff.org/insurance/upload/7566.pdf> (last visited June 22, 2011). Although the study found that for most people, the presence of co-payments did not translate to adverse health effects, low-income individuals who were also in poor health assigned to the free plan performed better on various health indicators than those in the co-insurance plan.

Id., at 6.

This is significant not only for its monetary value, but also because the Prevention Fund was created to strengthen non-clinical preventive activities. Allocating such a substantial portion of the Fund towards clinical providers defeats this goal in part. See generally U.S. Department of Health & Human Services, Fact Sheet: Creating Jobs and Increasing the Number of Primary Care Providers, available at <http://www.healthreform.gov/newsroom/primarycareworkforce.html> (last visited June 22, 2011).

ACA § 10501, 124 Stat. at 1000–01.

ACA § 5604, 124 Stat. at 679–80.

The Commission and Center will produce a National Care Workforce Assessment. ACA § 5103, 124 Stat. at 603–06.

Trust for America's Health, Prevention and Public Health Fund to Jumpstart Community-Based Prevention Programs, Press Release, 2010, available at <http://healthyamericans.org/newsroom/releases/?releaseid=215> (last visited June 22, 2011).

ACA §§ 4002, 5204, 5206, 5313, 5314, 5315.

For example, see Institute of Medicine, Who Will Keep the Public Healthy?: Educating Public Health Professionals for the 21st Century, 2002, at 51

Association of Schools of Public Health, Creating a Culture of Wellness: Building Health Care Reform on Prevention and Public Health, 2009, at 2, available at <http://www.asph.org/UserFiles/Prevention-and-Public-Health-Strategies-for-HC-Reform-asph-policy-paper2009.pdf> (last visited June 22, 2011).

With respect to financial incentives, see, e.g., Gosden T. Pedersen L. Torgerson D. , “How Should We Pay Doctors? A Systematic Review of Salary Payments and Their Effect on Doctor Behaviour,” QJM: An International Journal of Medicine 92, no. 1 (1999): 47–55 (concluding that salaries are associated with more preventive care and longer physician consultations)

For a critique of medical education's focus on the biomedical model, see, e.g., Muller D. Meah Y. Griffith J. Palermo A. Kaufman A. Smith K. L. Lieberman S. , “The Role of Social and Community Service in Medical Education: The Next 100 Years,” Academic Medicine 85, no. 2 (2010): 302–309, at 304, where the authors argue that “[t]he current focus in medical education on a biomedical model and organ-specific interventions, rather than on the characteristics of the family unit, the community, and the social and physical environment that contribute to health and disease, is inadequate.” With respect to the public's preoccupation with, and thus demand for, health care services,

See Hemenway , supra note 37.

For example, nurses are generally reimbursed by salary, while many physicians continue to be paid on a fee-for-service basis. The former is associated with longer patient consultations and the provision of more preventive services ( Gosden ., id.).

Barkauskas V. H. Schaffer P. Sebastian J. G. Pohl J. M. Benkert R. Nagelkerk J. Stanhope M. Vonderheid S. C. Tanner C. L. , “Clients Served and Services Provided by Academic Nurse-Managed Centers,” Journal of Professional Nursing 22, no. 6 (2006): 331–338, at 335.

See Beitsch ., supra note 52.

Stone D. H. , “Public Health in the Undergraduate Medical Curriculum: Can We Achieve Integration?” Journal of Evaluation in Clinical Practice 6, no. 1 (2000): 9–14, at 11.

Id.

See U.S. Department of Health and Human Services, supra note 44.

American Recovery and Reinvestment Act of 2009, Pub. L. No. 111–5, § 4101(a), 123 Stat. 115, 467–72 (2009).77. For a concise analysis of mandatory and discretionary “meaningful use” of electronic health records,

See Blumenthal D. Tavenner M. , “The ‘Meaningful Use’ Regulation for Electronic Health Records,” New England Journal of Medicine 363, no. 5 (2010): 501–504.

Id., at 501.

Hofman S. Podgurski A. , “Improving Health Care Outcomes through Personalized Comparisons of Treatment Effectiveness Based on Electronic Health Records,” Journal of Law, Medicine & Ethics 39, no. 3 (2011): 425–436.

For example, see Robinson B. , “Health IT Key to National Health Security Plan,” Government Health IT, 2010, available at <http://www.govhealthit.com/newsitem.aspx?tid=74&nid=74316>

(last visited May 17, 2011 noting that the Department of Health and Human Services' Biennial Implementation Plan for national security necessitates real time access to all electronic health records in the event of a national emergency).

For a general discussion of HiAP, see Stahl T. Wismar M. Ollia E. Lahtinen E. Leppp K. , Health in All Policies: Prospects and Potentials, Finland Ministry of Social Affairs and Health and the European Observatory on Health Systems and Policies, 2006.

Parmet W. E. , Populations, Public Health, and the Law (Washington, D.C.: Georgetown University Press, 2009): At 2 (introducing her theory of “population-based legal analysis,” according to which, the “law must acknowledge the critical importance of populations”).

See Elinder L. S. , “Obesity, Hunger, and Agriculture: The Damaging Role of Subsidies,” BMJ 331, no. 7528 (2005): 1333–1336.

Steinhauer J. , “Farm Subsidies Become Target Amid Spending Cuts,” New York Times, May 7, 2011, at A13.

See Perdue W. C. Stone L. A. Gostin L. O. , “The Built Environment and Its Relationship to the Public's Health: The Legal Framework,” American Journal of Public Health 93, no. 9 (2003): 1390–1394, at 1393 (stating ways in which the built environment is adversely affected by laws and suggesting that the public attempt to influence legislatures).

Corburn J. , “Confronting the Challenges in Reconnecting Urban Planning and Public Health,” American Journal of Public Health 94, no. 4 (2004): 541–546, at 544.

World Health Organization, “Health Impact Assessment,” available at <http://www.euro.who.int/en/what-we-do/health-topics/environmental-health/health-impact-assessment> (last visited June 22, 2011)

Quigley R. den Broeder R. L. Furu P. Bond A. Cave B. Bos R. , Health Impact Assessment International Best Practice Principles, Special Publication Series No. 5, International Association for Impact Assessment, 200688. S. Bondurant, “A New Chapter in an Old Story: Medicine and Public Health,” Transactions of the American Clinical and Climatological Association 108 (1997): 1–25, at 4.