This document summarizes key opportunities and threats to public health from recent health reform efforts. It outlines threats from potential budget cuts at state and federal levels. It also outlines opportunities from expanded insurance coverage through Medicaid expansions and health insurance exchanges in 2014. Specifically, it discusses opportunities for better coverage of preventive services, essential community providers, and integration into the primary care system. The document urges public health departments to build relationships and prepare tools to capitalize on reforms and ensure continued support for public health programs, despite ongoing uncertainties.

1. Health Reform
Implementation: Where
Things Stand
Mary-Beth Harty and Naomi Seiler
Department of Health Policy
George Washington University School of Public Health and
Health Services
August 16, 2011
The Department of Health Policy

2. Major Threats to Public Health
Funding
• State and local budget cuts
• Federal-level threats to health programs:
– Proposals to scale back Medicaid
– Demands for sharp cuts in discretionary
programs
– Added pressure of debt limit debate
– Bipartisan global spending proposals

3. Concern That Policymakers Will Think We
No Longer Need The Public Health System
• Many observers think health reform has
solved all our problems
• “Why do we still need HIV testing and
prevention programs?”
• Particularly challenging for “public health”
programs that do provide direct services,
like HIV testing

4. Opportunities for Expanded
Coverage
• 2014: Medicaid expansions
– Up to 133% FPL
– Childless adults, a key population for HIV programs
• 2014: Health Insurance Exchanges
– Subsidies for people between 133-400% FPL
• Other key insurance reforms that go into effect in
2014 (incl. no pre-ex condition exclusion)
• Already in place: Pre-existing condition
insurance plans
• Young adults up to age 26 remaining on parents’
insurance
– Another key population for NCHHSTP

5. Opportunities for Better Coverage
of Key Services
• Better coverage of preventive services
– “new” plans have to cover USPSTF recs, ACIP recs,
HRSA re children’s health and re women’s health
– IOM recommendation re HIV testing
• Essential Health Benefits
– Sets floor for services in exchange plans and
Medicaid expansion plans
– Includes category of preventive services
– Based on “typical employer coverage”

6. Opportunities for Integration into
Primary Care System
• Essential community providers
– Exchange plans will have to network with providers
that serve medically underserved populations
• Medicaid health homes - can include HIV
• Community health centers
– Expansion
– Ongoing safety net role

7. Opportunities Specific to
Public Health
• Prevention and Public Health Fund
– Dedicated mandatory funding stream for public health
– Survived Congressional challenges so far
• Community Transformation Grants
– NCHHSTP partners should identify primary applicants
and work with them to supplement primary goals
– One major component is increasing access to key
clinical services
• National Prevention Strategy
– Includes sexual health as a targeted priority area

8. Start Building Relationships Now
• Important to have relationships in place before
changes roll out:
– Other components within health department
– Other state agencies (education, etc)
– State Medicaid programs
– Provider organizations
– Community health centers
– State insurance commissions
– Exchange implementing agency and planning
councils
– CTG grantees (if not already part of the consortium)

9. Important Tools for ACA
Implementation
• HIT
• Billing capacity
• Communications capacity
• Referral systems
• Policy tracking (federal and state)
• Safety net capacity
• Best practices
• Strategic planning

10. Key Sources of Information For
Health Departments
– CDC
– State director groups (NASTAD, NCSD, etc)
– Disease-specific advocacy groups
– Kaiser
– NACCHO/ASTHO
– TFAH
– Others?

11. Uncertainty About ACA’s Fate
Doesn’t Justify Inaction
• The goal for today is to adapt to a changing
system – even if we don’t know the precise
trajectory.
• The steps that HDs should take – building
relationships, assessing strengths and
weaknesses, integrating into primary care – can
and should happen anyway.
• HDs have to experiment with new ways of
partnering and working to meet public health
goals.

12. Thank you.
mary-beth.harty@gwumc.edu
nseiler@gwu.edu