Health Reform and Healthy People Initiative

Abstract

The passage of the Affordable Care Act builds on and strengthens the foundation for prevention and wellness that Healthy People—the nation's health promotion and disease prevention aspirations for a healthier nation—established. The Affordable Care Act reaffirms the themes of Healthy People by promoting population-based prevention and sets the stage for Healthy People 2020.

The heart of Healthy People 2010 lies in its leading health indicators, reflecting high-priority health issues for the nation. National progress requires broad application of the ecological health model.

We reviewed the status of each Healthy People 2010 indicator and noted how the Affordable Care Act drives future positive health outcomes using the ecological model of health as a prism for viewing health improvement.

THE PASSAGE OF THE Affordable Care Act (ACA), the historic health reform legislation signed into law in 2010, promotes access to care and strengthens consumer protections. But by supporting the integration of clinical medicine with population-based prevention, the ACA also builds on and strengthens the foundation for prevention and wellness established by Healthy People, the nation's health promotion and disease prevention aspirations for a healthier nation.^1–3

Healthy People sets goals for a robust and efficient health care system, facilitates healthy behaviors, and strives for healthy communities, families, homes, and worksites.⁴ Moreover, it concretely applies the ecological model of health (Figure 1), placing the individual biology of disease within the context of the entire life course as well as the social and physical environments where people live, work, learn, and play. In this way, Healthy People captures the critical and modifiable determinants of health that most affect length and quality of life. The heart of Healthy People 2010 (HP2010) lies in its leading health indicators—reflecting high-priority health issues for the nation. National progress on each indicator requires broad application of the ecological model of health.

FIGURE 1—

Ecological model of determinants of health from Healthy People 2020, 2008.

Source. Reproduced from the Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. Phase I report recommendations for the framework and format of Healthy People 2020; 2008 (http://healthypeople.gov/hp2020/advisory/PhaseI/PhaseI.pdf).

HOW AFFORDABLE CARE ACT ALIGNS WITH HEALTHY PEOPLE

The ACA reaffirms the themes of Healthy People by promoting population-based prevention in several ways. First, as of September 2010, all new group plans and insurance policies must cover, at no cost to patients, effective clinical preventive services recommended by the US Preventive Services Task Force, the Advisory Committee on Immunization Practices, and the Health Resources and Services Administration. Second, the ACA creates a National Prevention, Health Promotion, and Public Health Council that will help formulate a National Prevention Strategy. The strategy will recognize and incorporate the ecological model of health that underscores the importance of various health influences such as access to healthy foods, prevention of violence, access to quality education, and employment.

Third, the ACA establishes a Prevention and Public Health Fund that will provide $15 billion in new funding over the next 10 years to expand and sustain the necessary infrastructure to prevent disease; detect it early; and, in concert with other provisions in the ACA, manage conditions before they become severe. Finally, the ACA authorizes investment in a host of other programs, including the National Health Service Corps and community health centers that will strengthen the public health infrastructure for the future.

In these ways, the ACA also sets the stage for Healthy People 2020 (HP2020), released in December 2010, which sets the national health objectives for the decade⁵ and the new HP2020 goals. These include creating social and physical environments that promote good health as well as promoting quality of life, healthy development, health equity, and healthy behaviors across life stages. The new iteration builds on the evolving evidence base of public health provided by the Guide to Community Preventive Services,⁶ its companion Clinical Guide,⁷ and related activities. Taken together, these offer a systematic framework for assessing the effectiveness of population health initiatives and clinical services. The evidence base is also bolstered by the emergence of health impact assessment and forecasting as tools to provide the best available information on effectiveness and magnitude of impact.^8–10

We reviewed the status of each HP2010 indicator as of 2008¹¹ (the HP2020 leading health indicators were released October 31, 2011) and noted how the ACA drives future positive health outcomes using the ecological model of health as a prism for viewing health improvement.

Physical Activity

In recent decades, Americans have reduced physical activity in their daily lives, increasing the risk of cardiovascular disease and some cancers. Healthy People data show that the proportion of people older than 18 years who engage in moderate (30 minutes/day moderate intensity) or vigorous (> 20 minutes at least three times/week of vigorous intensity) physical activity has remained stagnant for the past decade. In 2008 it was 32%, far below the HP2010 goal of 50%.

The Guide to Community Preventive Services recommends making physical activity the easy choice by reengineering our communities with accessible parks and recreation; encouraging the social norm of walking, bicycling, and climbing stairs where these activities can reasonably substitute for driving and riding elevators or escalators; and placing greater emphasis on mass transit and mixed residential and commercial development¹² to encourage greater spatial integration of places where people live, work, and shop. The ACA-authorized Community Transformation Grants will build on community-based prevention grants funded by the Recovery Act to enable multisectoral ways to promote physical activity and other health outcomes through a “health in all policies” approach, including education, planning, and transportation.

Overweight and Obesity

With two thirds of adults obese, the initial HP2010 objective of 15% remains a distant target. Among the important strategies for reversing the trend are policies to improve (1) access to healthy foods in schools, worksites, and communities; (2) more responsible marketing of processed foods high in fat, salt, and sugar, especially to children; and (3) educational initiatives that complement efforts to increase physical activity.^13–15

The ACA supports reducing overweight and obesity in several ways. For example, the Food and Drug Administration is charged with implementing new federal requirements for nutrition labeling of foods sold at certain chain restaurants and similar retail food establishments. Menu labeling will raise awareness of the caloric load in foods and, in conjunction with other initiatives, has the potential to reduce intake as much as 10%.¹⁶ One health impact assessment of this strategy estimated that caloric information on the menus and menu boards at fast food restaurants could substantially reduce weight gain in adults and children older than five years.¹⁷

To encourage employers to address overweight and obesity, authorized provisions in the ACA include expanding the premium discount that employers can offer as financial incentive to induce participation in weight control programs, providing employers with technical assistance and best practices, and establishing grants to small employers that wish to begin offering comprehensive worksite wellness programs. In addition, the ACA supports the creation of a Healthy Weight Collaborative administered by the Department of Health and Human Services’ Health Resources and Services Administration; in this effort, multisectoral partners will engage states and local communities in linking public health and primary care to prevent and treat obesity in children and families.

Tobacco Use

Despite some progress in reducing tobacco use, smoking rates have stalled and remain unsatisfactorily high (20% among adolescents and 21% in adults compared with Healthy People targets of 16% and 12%, respectively).¹¹ The ACA directly addresses this issue through numerous health system and broader public health reforms. For example, clinician interventions should be enhanced through the ACA by removing financial barriers to accessing cessation services and creating medical homes and primary care systems that can ensure appropriate counseling, cessation treatments, and follow-up. In 2010, the Prevention and Public Health Fund awarded $15 million to states and communities to stimulate the delivery of evidence-based tobacco control programs and policies. These included community prevention activities that support telephone-based tobacco cessation services, outreach programs targeting vulnerable populations, and antitobacco media campaigns showing the negative health consequences of tobacco use.

Substance Abuse and Mental Health

Alcohol abuse and substance abuse remain major problems and require a multipronged approach. Twenty percent of adolescents aged 12 to 17 years used alcohol in the preceding month in 2008 (HP2010 target 9%), almost one quarter of adults binge drank over the same period (HP2010 target 13.4%), and 8.1% of adults used illicit drugs (HP2010 target 3.2%).¹¹ Screening for alcohol use in primary care should be enhanced by the ACA's strengthening the primary care system and its assurance of first-dollar coverage for clinical preventive services for new plans.

Similarly, depression, the leading cause of disability, accounts for two thirds of suicides.¹⁸ The ACA builds on previous laws requiring parity of coverage for mental health treatment, which should bring the country toward the modest Healthy People target of 50% of mental health and substance abuse patients receiving treatment. These measures can be augmented through the minimum benefits package to be made available through health insurance exchanges in 2014, which could ensure that essential mental health and substance abuse services are available to lower income populations through Medicaid and subsidized private insurance. The formal establishment of the Community Preventive Services Task Force in the ACA will enhance systematic approaches to prevent substance abuse and provide timely treatment. In 2010, funds from the Prevention and Public Health Fund were also dedicated to the integration of behavioral health into primary care settings to help prevent and reduce chronic disease and promote wellness by meeting the full range of patient health care needs.

Responsible Sexual Behavior

Ongoing challenges exist with the rising rates of sexually transmitted diseases and teen pregnancy. Nearly one in four women aged 14 to 19 years in the United States acquires at least one sexually transmitted infection.¹⁹ Rates of chlamydia infection continue to climb and, as with most sexually transmitted diseases, disproportionately affect non-White populations. The encouraging 34% decrease in teen pregnancies (from 1991 to 2005) halted in 2006, followed by a 5% increase over the next two years.²⁰

The Community Guide recommends evidence-based sex education programs because they enhance positive youth development, reduce risk behaviors, increase use of barrier protection, and reduce sexually transmitted infection.²¹ Increased access to care and creation of medical homes under the ACA will provide greater opportunities for counseling and screening, including first-dollar coverage for US Preventive Services Task Force–recommended sexually transmitted infection screening tests in all new health insurance policies. These efforts should diminish transmission and reduce sequelae of untreated infections, such as pelvic inflammatory disease and infertility.²²

Injury and Violence

Unintentional injuries continue to be the leading cause of death for people aged one to 44 years, and suicide and homicide are the next two leading causes for the 15- to 34-year age group.²³ Rates of motor vehicle crash deaths (14.4/100 000 in 2006) have declined modestly, whereas rates of homicides (6.2/100 000) have been stubbornly stable.¹¹ Both rates are virtually double their HP2010 targets of 8.0 and 2.8, respectively. Such violent deaths, a major cause of disparities in life expectancy, reflect the challenges of ensuring supportive communities and families, safety, educational and income opportunities, and a healthful built environment.

The National Prevention, Health Promotion, and Public Health Council created under the ACA will begin to address these multisector problems through a social determinants of health approach. Specifically, the federal government can partner more closely with a diverse group of stakeholders (including state, tribal, and local governments; private industry; and faith communities) to prevent injury within worksites, homes, neighborhoods, schools, and other settings.

Environmental Quality

Poor air quality, a focus of the leading health indicators, results in more than 60 000 premature deaths a year as the result of particulate matter smaller than 2.5 micrometers alone.²⁴ Current ozone exposure (36% of Americans in 2009), an important component of air pollution, exceeds the HP2010 target (0%).¹¹ Over the past decade, the importance of the built and natural environments to our health has become increasingly apparent. From climate change to our transportation systems and the design of our communities and homes, the physical environment is a major determinant of our health. Our automobile-dependent transportation system, for example, not only generates pollutants but also reduces our physical activity.

The National Health Promotion and Prevention Council has an opportunity to increase attention to our physical environment, a key determinant of health. Along with the US Department of Health and Human Services, the Environmental Protection Agency has long focused on health consequences of environmental exposures. The council, however, can look more broadly at the consequences of our transportation systems, agricultural policies, and community design and development, prompting a focus on health in all policies. Such a multisectoral discussion could, for example, highlight the advantages of increased investment in mass transit and in making communities more walkable and bikeable. The ACA also addresses these issues through the Community Transformation Grants.

Immunization

Although in the United States many of the vaccine-preventable diseases of childhood have almost disappeared and 70.5% of children younger than 3 years were fully vaccinated in 2009 (short of the 80% target), risks continue.²⁵ Many highly effective adult vaccinations remain significantly underutilized. Only 60% of adults older than 65 years have had pneumococcal vaccine and 67% an annual influenza vaccine, far below the HP2010 targets of 90%.¹¹ The ACA will ensure first-dollar cost coverage for immunizations recommended by the Advisory Committee on Immunization Practices for those in private insurance plans, reducing the financial barrier to immunization. In addition, electronic health records can bolster decision support to ensure adults and children are immunized in a timely fashion.²⁶

Access to Health Care

In 2008, 83% of Americans younger than 65 years were covered by insurance, compared with the HP2010 target of 100%.¹¹ One of health reform's major objectives has been to provide insurance and access to primary care for all Americans. Because of the ACA, 32 million Americans will have access to quality, affordable health insurance coverage. In recognition of the need to strengthen the primary care system, $250 million of the new Prevention Fund in the ACA was used to bolster the primary care workforce in fiscal year 2010. In addition, the ACA includes $11 billion in funding over the next five years for the expansion, creation, and support of community health centers making affordable, high-quality primary care services available to nearly 40 million people regardless of their insurance status or ability to pay.²⁷ Increased access to and use of primary care and clinical preventive services are essential to reduce breast and colorectal cancer mortality and control blood pressure and dyslipidemia.

HEALTHY PEOPLE 2020, A GENERATIONAL OPPORTUNITY

HP2020 places great emphasis on the social determinants of health and health disparities and includes education and income objectives. HP2020 also takes a more expansive view of the impact on health resulting from the built and natural environments. Building on HP2020, the National Health Promotion and Prevention Council provides a new vehicle for implementing a “health in all policies” strategy across government agencies. Many interventions in the National Prevention Strategy will span departments and sectors, affecting multiple health outcomes.

Implementation of the ACA is a generational opportunity to strategically attack underlying social and physical environmental determinants of health. Although it does not address all current challenges in population health, it will foster stronger links between population health institutions and medical care providers to create a healthier population. As an important complement to implementation, HP2020 will serve as the foundation for the National Prevention Strategy and facilitate national, state, and local prioritization of policy and program interventions. The National Prevention Strategy and other components of health reform strengthen evidence-based public health functions and work toward a health improvement and maintenance system embracing both medical care and public health that can improve the health of all Americans.