In Tulsa, local health officials are focusing on “health literacy” to help residents who signed up for insurance during last year’s sign-up period to re-enroll for the next plan year and to begin to think like consumers, according to Dart.
In SeaTac, a small city of about 28,000 between Seattle and Tacoma, Wash., city officials ran community events for people who speak English, Spanish, Amharic and Somali, signing up 2,300 residents for health insurance and Medicaid, says Mia Gregorson, the city’s mayor and also a member of the state house of representatives.
“There’s a huge variation around the country,” says Fleming of Seattle-King County. “But there’s no question that a lot more people have health care coverage than before the law was passed.”
While official government statistics based on the first half of 2014 show some modest decline in uninsured, more current survey data from places like the Commonwealth Fund, Rand Corporation and the Urban Institute indicate about a 5 percent drop in the uninsured population or a 10 to 12 million increase in those with private insurance (including children up to 26 years old). Hospitals are also reporting they are seeing fewer uninsured patients.
Health care total expenditures have also risen at a slower rate, with projections from the federal Center for Medicare and Medicaid Services that the trend will continue, although some attribute this to the transitory effects of the recent recession. Others look to statistics from the president’s Council on Economic Advisors showing a decline in hospital readmissions, due to ACA financial penalties, as a concurring indicator that incentives are working.
Public health officials believe that some of the improvement in hospital performance can be attributed to their work in bringing together the various parts of the health care system.
As part of the legislation, non-profit hospitals must develop a community health care needs assessment. Health officials have used the mandate as a springboard to develop participation from an even broader spectrum of providers.
“Public health officials are leaders in their work,” says Julia Joh Elligers, NACCHO’s director of Assessment, Workforce and Planning. “We are focusing on public health-primary care integration, asking what it would look like if public health and clinical care work together. “
In Santa Fe, the community assessment revealed a health issue that was not previously apparent, says County Commissioner Liz Stefanics. By bringing together the various organizations that were treating the poor, the county learned that a high percentage of pregnant women were also abusing drugs and alcohol. “We were able to bring attention to a major problem,” she says. “It’s a specific case that came up from the assessment.”
As a result of the study, hospitals, county clinics and primary health care clinics are all now devoting more attention to treating the woman and the newborn for substance abuse. “We are able to streamline information and the treatment process,” she says.
In Tulsa, health officials have been able to bring insurance providers into the public conversation, which had never happened before the ACA, Dart says. “We were able to get people enrolled at the time of screening for health issues,” he says. “It’s a huge positive with health providers included in the discussions.”
Gregorson of SeaTac says that funding through the ACA has allowed the city to expand services, though the law itself cannot cope with the problems of a community with high levels of poverty. “The ACA can only help so much,” she says.
Through the ACA, the community has been able to expand its community health centers and provide additional treatment for the population, which now has better access to treatment through the raising of Medicaid eligibility. “Where we have been able to expand, it has been awesome,” she says. “But we’re not sure where the funding will come from after three years. We want to make sure this is not a one-time thing.”
She points to growing budget issues facing the county and the prospect of limited resources as posing a danger to successfully implementing the legislation. “We want to make sure that the county is thoughtful when making cuts,” she says. “It’s ultimately tough to provide health care if you don’t have clinics ready to go.”
Still, she is optimistic at least for the near term. “It’s been exciting,” she says. “We expect to see a second wave of sign-ups” when the new enrollment period begins in November.
In San Diego County, officials took a multi-pronged approach to engage prospective enrollees in the state MediCal program, which prompted innovative solutions to the challenges created by the new law, says Macchione. For example, he says, the area’s cities and the county networked their phone systems that rolled overflow calls from a site hit with a backlog to another site that could handle the overflow.
What really excites Macchione is the prospect of leading the county through a transition to a new delivery system that focuses on a broader definition of health care. Rather than just providing cash for food stamps, he says, people must be enabled to get better nutrition. “That raises the question of how we help with health education,” he says. “It becomes public education. How do we make people more self-sufficient, how do ensure that they are healthier?”
The ACA was at the “nexus” of preventive care integration, focusing on the importance of combining the data from physicians with hospitals, to create a blended approach. “We need to develop strategies to further leverage the advances brought on by the ACA,” he says.
Fleming of Seattle-King County also sees a broader vision for public health, tying health care to other underlying conditions in people’s lives that must be addressed to keep people out of the hospital. “People who are newly enrolled are poor,” he says. “We see that housing, unemployment are underlying issues that need a response. People have a hard time keeping healthy unless they have housing. We need to change the health system to a health and human services delivery system.”
Some of the most innovative work in this area, he says, is through waivers of certain Medicaid laws that allow for financing of related services. In addition, investors are studying strategies that would float bonds to finance health care initiatives. “We are at a point where almost everybody is insured,” he says. “We need to increase incentives in the system to invest in community-based prevention, shift the financial incentives from how much health care you do to keeping patients healthy. We are all collectively trying to chart our course.”
While strongly endorsing this comprehensive approach, Elligers of NACCHO sees difficulties facing public health organizations, as they work through the changes prompted by ACA. For example, some organizations depend heavily on clinics to balance their budgets, but now see more competition for their services from private providers. In addition, public health providers are now just learning how to manage their way through the insurance reimbursement system for newly enrolled patients.
“It’s complicating their operations,” she says. “They have to become more business-oriented. They have to think about return on investment. Where are they getting the most for their dollar? What line of work does public health do well? It’s hard to think through all the factors, all of the community players. It’s very complicated.”
She says public health organizations continue to play an increasingly important role in shaping the health care system of the future, integrating the treatment of health issues of the individual with other factors critical to maintaining a lifetime of quality living.
“These organizations will continue to advocate for public health,” she says, “and educate the other stakeholders on what public health contributes. We will make sure that we insert ourselves into the conversation.”
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