In the United States, the term "health care" has long been viewed as exclusively describing the delivery and funding of medical services rather than the management of population behavior in a manner that potentially decreases the ultimate need for such expensive medical services. A point of tension preceding the Affordable Care Act that has been greatly amplified by that law's passage is this: does it make sense for the government to finally combine the principles of care delivery and population health as equally important elements in a reformed version of national health care policy?
At least in part, the ACA's provisions have answered in the affirmative with their new emphasis
Photo: Hoag Levins
Stephanie Hoffmann, JD, MBE, is Legal Analyst and Project Manager of the Health Insurance Exchange Project at the Leonard Davis Institute of Health Economics with the University of Pennsylvania.
on access and preventive care -- topics that were the focus of the AcademyHealth National Health Policy Conference's "Opportunities for Improving Population Health in the ACA" session. The two panelists -- Andrew Rein, CDC's Associate Director for Policy and Natasha Coulouris, Senior Public Health Advisor for the Health Resources and Services Administration (HRSA) -- made little mention of the law's health insurance exchanges or how they increase access to health insurance and facilitate new levels of preventive care for a broader population.
One of the most important ways insurance exchanges will support public health is by increasing access to the non-emergent care millions of uninsured U.S. residents currently don't receive. Federal subsidies for the coverage will be available to individuals between 133% and 400% of the federal poverty level.
But the law recognizes that coverage is not enough and requires health insurance plans to provide meaningful access to quality care. Every plan sold on an exchange must meet minimum coverage requirements called "essential health benefits," which the exchange establishes by selecting a benchmark plan currently offered in the state. These benefits must include elements such as preventive care, prescription drugs, maternity and newborn care, and mental health services, and states must ensure that plans cover enough providers to make it possible for patients to actually see a doctor in their area.
One area where public health differs from care delivery systems is in its focus on outreach. Exchanges provide a potentially rich opportunity to educate their users about the importance of primary care and its availability. The majority of messages people receive about their health is from their provider or their insurer. The uninsured population and those who do not frequently access the health care system are therefore at a significant disadvantage. Public health efforts often target this population to improve their understanding of chronic conditions, coverage options, and basic preventive health issues like nutrition and safety.
Health insurance exchanges provide a new opportunity to interact with these individuals, direct them to important health information, and help them get covered. The ACA's "no-wrong door" provision actually requires exchanges to work seamlessly with other benefits programs like Medicaid to assist individuals in finding coverage, even if they cannot purchase it on the exchange itself. This mirrors much of the work done in the public health community, creating an excellent opportunity to work together and ensure coverage.
Recognizing the role many public health and other community organizations play in guiding individuals to health care coverage, the law includes this third-party involvement as part of the exchanges. Navigators, or neutral third-party advisors familiar with the exchanges and health coverage landscape in a state, will receive grants to help community members learn how to enroll in the exchanges and how to find coverage that best fits them. Many public health organizations already provide this service, and the navigator program enables states to award grants supporting these activities.
Public health efforts focus on the population as a whole, and as such, rely heavily on data to guide and evaluate programs. As part of their operation, state health insurance exchanges will collect a great deal of data from their users. These de-indentified data will be especially valuable to the public health community both for their content and their breadth. Exchanges will be able to gather information on a population that interacts less frequently with health systems (and about whom it is currently more difficult to gather data), and will be doing so across the country in similar or even identical ways, making the data more useful to managers as well as researchers.
While the ACA's health insurance exchanges will provide a number of opportunities to further public health objectives, there are a number of areas where there is clearly room for improvement.
Exchanges will not cover everyone who is currently uninsured, and after the Supreme Court decision in 2012, many states have opted not to expand Medicaid coverage for those with income below 133% of the poverty level. The ACA also changes the way some community health providers are funded, which means that the health care safety net is going to change in the coming years.
Going forward, public health professionals will have to work with exchange officials and members of the health care industry to further the law's ultimate goal of improving population coverage and health.
